Is the Criticism of John Keats’s Doctors Justified? A Bicentenary Re-Appraisal

ABSTRACT John Keats died of consumption in Italy on 23 February 1821. He was treated both in London and in Rome by eminent physicians who have over time been criticized for failing to diagnose that Keats had pulmonary tuberculosis. The evidence for this censure, from the letters of Keats and his companions, along with the publications of Dr James Clark, his physician in Rome, is reviewed and the contemporary treatment of consumption in the early part of the nineteenth century is analysed. We argue that Keats’s doctors have been unfairly castigated by modern scholars and that in fact they applied the medical advice for the treatment of consumption that was available at that time.

Hillas Smith developed this argument further in his book Keats and Medicine when he wrote In a patient with advanced tuberculosis who has abdominal pain and vomiting it would be a reasonable assumption that the disease had involved the intestines. This may have been what Clark meant when he said that the seat of Keats's trouble was the stomach. It should be made clear that it has not and now cannot be substantiated that Keats did in fact have abdominal tuberculosis. What is surprising is that Clark, who had a special interest in phthisis, and presumably having been informed of his new patient's family history as well as the diagnosis of the London physicians together with the express purpose of Keats's sojourn in Rome, should come to a conclusion concentrating on stomach and mind rather than the lungs as the major site of the disease. 4 However, in 1821 when Clark aged 31 was in Rome he was in the early stage of his medical career. In particular he was amassing information on the management of patients with consumption, which he later published in several books between 1830 and 1836. Did Clark know that Keats had pulmonary tuberculosis? Keats certainly was very ill when he arrived in Rome after his long journey from England. Keats's doctors in England however, had originally considered his condition to be nervous in origin. 5 In this paper it is asserted that Clark did know Keats had consumption which he believed affected both Keats's stomach and lungs. He treated him with a restricted diet, he advocated regular exercise and he performed repeated venesection (bloodletting). We also argue that Clark was in fact applying the knowledge then available for the management of consumption and that his approach to the treatment of John Keats was entirely rational.

John Keats's Fatal Illness
Keats possibly started to show signs of developing consumption in 1818 after his walking tour of the north of England and Scotland with his friend Charles Armitage Brown (1787-1842) when, towards the end of this journey he complained of a sore throat. Lord Brock, however, carefully analysed the presenting symptoms of Keats's sore throat and concluded that there was no evidence of tuberculous laryngitis or pharyngitis. 6 The first real evidence that Keats was developing consumption came on 3 February 1820 when he began to cough up blood (haemoptysis). 7 Charles Brown recorded 'That is blood coming from my mouth.' I went towards him; he was examining a single drop of blood upon the sheet. 'Bring me the candle, Brown; and let me see this blood.' After regarding it steadfastly, he looked up in my face, with a calmness of countenance that I can never forget, and said,-'I know the colour of that blood;-it is arterial blood;-I cannot be deceived in that colour;-that drop of blood is my death-warrant;-I must die.' 8 On 6 February 1820 Keats wrote to his sister Fanny (1803-1889), explaining that he had caught a cold 'which flew to my lungs'. 9 On 10 February 1820 he wrote to Fanny again stating that he was taken ill, 'when so violent a rush of blood came to my Lungs that I nearly suffocated.' 10 However, by 19 February 1820 Keats was feeling better and he wrote to Fanny Keats, 'The Doctor tells me there are no dangerous Symptoms about me and that quietness of mind and fine weather will restore me.' 11 Keats was then seen by Dr Robert Bree (1759-1839) 12 a physician who specialized in treating patients with asthma, particularly with the administration of digitalis. 13 He was also one of the few physicians in England at that time to possess a stethoscope, invented in 1816 by René Laennec (1781-1826. 14 Dr Bree's opinion though was that Keats's condition was nervous or psychosomatic. However, it did not prevent Dr Bree trying the effects of digitalis on Keats, in a dose high enough to cause nausea. 15 On 21 April 1820, Keats wrote to Fanny Keats, 'The Doctor assures me that there is nothing the matter with me except nervous irritability and general weakness of the whole system, which has proceeded from my anxiety of mind of late years and too great excitement of poetry.' 16 It would therefore appear that the doctors were of the opinion that his condition was nervous, and his palpitations were brought on by anxiety. Did these doctors say there was little wrong with him because he was a poet? A poet, by definition, is someone artistic and creative by nature, and therefore inclined to embellish words through poetic exaggeration. For example, if Keats had been a landlord or a banker would they have diagnosed his condition differently? On 22 June 1820, Keats had another episode of bleeding and wrote to Fanny Keats, 'As I was setting out yesterday morning a slight spitting of blood came on which returned rather copiously at night'. 17 Keats wrote further to his sister in July that he was getting a little stronger, but his physician had told him that he must arrange to pass the winter in Italy. 18  Keats's neurosis, and following the haemoptyses they advised him to get way from the damp English climate. Keats wrote to Brown on 20 August 1820 that he had resolved to go to Italy either by sea or land, 20 and that a physician to look after him in Rome had been found, 'I am to be introduced before I set out to a Dr Clark a physician settled in Rome who promises to befriend me in everywhere there.' 21 As it happened, the meeting in London between Keats and Clark never occurred and Keats travelled to Italy on 17 September 1820, accompanied by his friend the artist Joseph Severn (1798-1879). Keats sailed in the Maria Crowther, a single decked 130 ton two-masted brig built in 1810. Four passengers 22 and the captain all shared the one cabin. The voyage was long, lasting 38 days and was beset by storms.
On 21 October 1820, when they arrived in Naples, Keats was not well and was suffering the effects from the long journey. Severn records that in Naples blood came from Keats's stomach and he had a fever at night and also suffered violent perspiration. 23 Keats, in his letter to Fanny Brawne's mother on 24 October 1820, identifies his problem as being in his stomach: 'At the moment I am suffering from indigestion very much.' 24 Keats arrived in Rome on 15 November 1820. He had a letter of introduction to Dr James Clark, who, though, was not expecting him. 25  Macbeth when talking to Lady Macbeth's doctor? Was Clark really saying that all of Keats's condition was also in the mind? On 30 November 1820, Keats wrote to Charles Brown, 'Tis the most difficult thing in the world for me to write a letter. My stomach continues so bad, that I feel it worse on opening any book,-yet I am much better than I was in quarantine [. . .] Dr. Clark is very attentive to me; he says, there is very little the matter with my lungs, but my stomach, he says, is very bad. 29 Was Clark being entirely honest with Keats about his condition? He told him that the disease had affected his stomach but said there was little the matter with his lungs. Did he think that Keats's condition was too far advanced for there to be any hope of success from medical treatment? We would suggest that Clark was being a compassionate doctor, only telling his patient about a possibly treatable condition and hiding his suspicions from Keats that his lungs were affected. At this stage Severn was also questioning the effect the long journey had on Keats: I do lament a thousand times that he ever left England-not from the want of medical aid or even friends-for nothing can be superior to the kindness of D r Clark &c-but the journey of 2000 Miles was too much in his state-even when he left England-and now he has most surely broken down under it-30 On 9 December 1820, Keats had another episode of haemoptysis and Severn called for Dr Clark who treated Keats by venesection, draining eight ounces of blood. 31 Unfortunately this was followed the next day by a further episode of haemoptysis which again resulted in bloodletting. 32 By this time Keats was confined to his bed and was extremely hungry and had a distended stomach. Clark kept Keats on a strict diet as he believed his abdominal organs were disturbed and hence nothing would be digested. Throughout this time Dr Clark visited Keats regularly, even calling at the apartment four or five times a day. 33 Severn wrote to Taylor (Keats's publisher) on 24 December 1820, he has had another attack of bleeding from the lungs which has weakened him greatly, and he is now in a most deplorable state.-His stomach is ruined and the state of his mind is the worst possible for one in his condition [. . .] His digestive organs are sadly deranged and his lungs are also diseased-either of these would be a great evil, but to have both under the state of mind which he unfortunately is in must soon kill him. 36 In the same letter, Clark also wrote that when he first saw Keats he thought something might be done 'but now I fear the prospect is a hopeless one'. 37 It is therefore clear that by this stage Clark knew Keats was suffering from consumption involving his lungs and digestive system and that he was dying.
On 15 January 1821, Clark wrote a letter to an employee of Taylor's, mainly concerning obtaining money for Keats, 'Poor fellow he is now so ill as to be constantly confined to bed, his stomach is still in a very bad state, the affection of his lungs is increasing and the state of his mind is the most deplorable possible'. 38 Tragically John Keats's consumption progressed, and he died in Severn's arms at eleven o'clock at night on 23 February 1821.
On 25 February 1821 Clark carried out a post-mortem examination in the company of an Italian doctor, Dr Luby, which Severn records, 'they thought it the worst possible Consumption -the lungs were intirely destroyed -the cells were quite gone'. 39 However, there appear to be no records of the state of Keats's abdominal organs. Keats was later buried in the Protestant cemetery in Rome. 40 All his bedding and furniture were burned (at a cost to Severn of £150), as the Italians were believers in the contagious nature of consumption. 41

Consumption in 1820-1
Consumption in that period was a common disorder. John Marshall (1783-1841) in his book Statistics &. Mortality of the Metropolis reported that in 1821 one third of all deaths in London were due to consumption and that the total number of deaths from consumption was increasing ( Figure 1). Consumption was known to be a chronic disease that affected all parts of the body. It was recognized from post-mortem studies that tubercles could be found both in the lungs and in the abdominal organs. 42 In the period there was debate as to whether consumption was contagious. William Buchan (1729-1805) stated that infection is one cause of consumption: 'Consumptions are likewise caught by sleeping with the diseased'. 43 Clark though did not believe in the contagion theory. When he found that the hospitals in Rome had special wards for tuberculosis, he condemned this as 'due to the obsolete idea of consumption being contagious'. 44   In 1815, his last ship, the Maidstone, was paid off and Clark returned to Edinburgh to continue his studies, graduating as a Doctor of Medicine on 1 August 1817. In 1818 he accompanied a patient who had advanced consumption to the south of France, and he visited many different cities, developing his interests on the effect of climate on consumption. He collected data in different cities on the pressure of the atmosphere, the level of rain and the temperature, with a view to studying their influences on the disease. In 1819 Clark settled in Rome where he remained for several years treating mainly the English community. Among his patients was Prince Leopold of Saxe-Cobourg (1790-1865) who appointed Clark his personal physician. 48 53 It is therefore clear that sixteen years after leaving Rome Clark had become a senior and well-connected member of the medical establishment.
In 1839 Clark was implicated in a major scandal concerning one of the ladies in waiting, Flora Elizabeth Rawdon-Hastings (1806-1839), who was a Maid of Honour to Queen Victoria. In 1839 she had been observed by her companions to show signs of pregnancy and Clark was asked to give an opinion on the matter. This assumption that she was pregnant was later shown to be baseless and Lady Flora died that same year from a malignant abdominal tumour. In his defence of the personal criticism that he received Clark made a statement in which he explained that he went to see Lady Flora, when they were both in Scotland, because she had been noted to have developed a large swelling in her abdomen. Clark  Consequently, on the 17 February 1839, Sir James Clark and Sir Charles Clarke issued a joint statement: We have both examined with great care the state of Lady Flora Hastings with a view to determine the existence or nonexistence of pregnancy and it is our opinion although there is an enlargement of the stomach that there are no grounds for the suspicion that pregnancy does exist or ever did exist. 55 Clark survived this controversy and continued as physician to Queen Victoria and to Prince Albert (1819-1861). 56 Sir James Clark died aged eighty-one on 29 June 1870 in Bagshot Park. 57 His obituary states that "he was a man of great knowledge of the world and of cool and sober judgment." 58 Clark was widely sought after during his later life as a medical opinion and indeed in 1848 Charles Dickens (1812-1870) brought his sister Fanny to see him for advice when she was dying from consumption. 59 Clark was also consulted by Frédéric Chopin (1810-49) in London during his last illness, and wisely simply advised Chopin to return to Paris, and Chopin added that Clark 'gave him his benediction'. 60 Robert Louis Stevenson too consulted Clark and was advised to seek out a more suitable climate in the high Swiss Alps, the Mediterranean, the Engadine Valley, or Colorado. 61 In 1823 Severn asked Clark's advice when he was unwell and was told that he needed to pay attention to his stomach and he would be well and strong 62 Severn lived to the age of 86.

Clark's Treatise on Pulmonary Consumption
In the introduction of this book on Sanative Influence of Climate, Clark states, 'I have endeavoured to show that the disordered states of the stomach are intimately connected with the origin of diseases of the chest and with tuberculous infections in general.' 63 He defined consumption as being a constitutional disease which precedes and is the essential cause of pulmonary disease. 64 Clark classified consumption as being either acute and latent or chronic and hereditary and he discussed the role of the digestive organs in relation to lung disease. Clark argued that in consumption the digestive organs are often deranged and until they were improved little progress could be made in treating the condition. 65 Clark also emphasized that the stomach was the organ in which tuberculosis often occurred and that it was related to the venous congestion of the abdominal viscera which then resulted in pulmonary consumption. 66 His reasoning was that inflammation of the mucous membrane of the stomach and the rest of the alimentary canal frequently occurred as the disease progressed. 67 Consequently a patient who complained of stomach pain and developed what he labelled Gastric Dyspepsia had gastric inflammation which could then progress onto bronchial inflammation, which in turn can result in what Clark termed Tuberculous Cachexy. He defined this term as 'the morbid state of health that precedes and constitutes the essential cause of pulmonary consumption'. Clark wrote that during this state the patient is 'pale and shallow, has dull eyes and is in the end stage of the disease' (Figure 2). 68 Clark noted that haemoptysis 'is in general to be regarded as an indication of the presence of tubercles in the lungs'. 69 Clark discussed what he considered to be an ideal climate for a patient suffering from consumption. He advised a change from the crowded city to open countryside and from cold to warmer climates. 70 Clark suggested Rome was an ideal place for a patient with gastric dyspepsia, especially during the spring. It was at a higher altitude than London being 163 feet above sea level and there was a stillness of air with moderate winds, namely the sirocco, which kept the city clean. 71 Clark suggested that the Spanish Steps and Piazza di Spagna were a healthy quarter in Rome and he noted that pure tubercular consumption was not very frequent in that city.
Clark described in detail the treatment available for patients where there was inflammation of the stomach. He laid out a programme including a mild diet free from any stimulating seasoning to be combined with water and in small doses, wine, preferably from Bordeaux. He advised that the diet should contain an anchovy a day which could be supplemented by antimony as a tonic. 72 Clark was a strong advocate of exercise, albeit in moderation. He explained that when irritation of the stomach was complicated with a bronchial membrane disease 'horse riding should be chiefly relied on for exercise.' 73 Clark listed a variety of different drugs and treatments for patients with consumption and these included mercury to work on the secretion of the liver, iodine to reduce abdominal plethora, antimony as an emetic and taraxacum (the common dandelion) for abdominal congestion. These he suggested should be combined with expectorants, and emetics, along with cold baths and cold sponging. 74 Clark was emphatic that bleeding was a very important part of the management of patients with consumption. The principle of bleeding a patient was based upon the concept that there was venous congestion of the abdominal organs which needed relieving. The process of bleeding meant that small amounts of blood, usually six to eight ounces at a time, would be regularly removed thereby reducing congestion in the abdominal and pulmonary organs. In a patient with haemoptysis Clark particularly recommended bleeding to treat the venous congestion stating, 'I have never had the occasion to regret the employment of bleeding', especially when the patient has had natural discharges of blood. 75 It is worth noting that William Buchan also stated that bleeding was 'the only thing' for inflammation of the stomach. 76 Isaac Burney Yeo (1835-1914), a respected chest physician, writing in 1895, condemned the use of bleeding: 'bloodletting will rarely be an appropriate remedy for the haemoptysis of phthisis', while still recommending the use of quinine and digitalis for the fever, and endorsing the importance of good food, climate and exercise. 77

Clark's Treatment of Keats
On what basis is Clark's treatment of Keats in Rome open to criticism? Did Clark know that Keats had pulmonary consumption? Clark was surely aware that Keats had nursed both his mother Frances and his brother Tom with tuberculosis, and whether one believed the disease was contagious, or like Clark, that it was constitutional and the susceptibility could be inherited, the diagnosis would have been high on the list of possible diagnoses. 78 It is relevant that Clark later looked after the philosopher John Stuart Mill (1806-1873) who also had a family history of tuberculosis, and Clark took some time to diagnose organic disease of the lungs despite Mill having haemoptyses. Clark originally ascribed the symptoms to a sudden change in the weather. 79 In his letter of 27 November 1820 when he first saw Keats, Clark diagnosed that Keats had primarily a stomach disorder, although he was suspicious that Keats had disease in both his heart and lungs. However, Clark also placed great emphasis on Keats's nervous state, something Dr Bree had originally diagnosed even though Keats at that time had had an haemoptysis. Buchan's Domestic Medicine which reflected the standard medical treatment in 1820 for patients with consumption also advocated a change of air, exercise, preferably riding, an easily digestible diet, and quinine for purulent sputum; and noted that 'in the first stage of a consumption, the cough may sometimes be appeased by bleeding'. 80 Did Clark use a stethoscope when examining Keats in Rome and would this have helped him make the diagnosis of pulmonary consumption? In 1819 when Clark was in Rome he travelled to Paris to see Laennec demonstrate its uses, though Clark wrote, It would require more time than I had to bestow to make myself fully acquainted with the use of this instrument, Nevertheless I observed enough to convince me that much useful information is to be acquired through the medium of this instrument in distinguishing the disease of the different viscera of the thorax. 81 Clark was impressed by the stethoscope as an instrument for diagnosing patients with diseases of the lungs. Although it is unknown whether he used a stethoscope when examining Keats, it would appear that he was acquainted with it but had not yet mastered the technique. 82 Later in his books Clark promoted the importance of the stethoscope in the diagnosis of patients with pulmonary disease. He explained that the stethoscope was particularly valuable in examining the area immediately below the clavicle and also in the axilla. 83 Why did Clark persist in treating Keats with bloodletting? René Laennec's exemplary volume on Diseases of the Chest (published in French in 1819) stated that, apart from a couple of specific indications, 'bleeding ought never to be employed in the treatment of consumption'. 84 Clark would have been aware of this as it was on his recommendation that Laennec's treatise was translated and published in English. Indeed, although bloodletting was used in sailors with fevers, 85 an early controlled trial of bloodletting in camp fever in the military during the Peninsular War, published in 1816, showed a marked survival advantage for the two unbled groups. 86 Nevertheless Clark's advocacy of bloodletting was common practice at that time. Interestingly a discussion on bloodletting published in the Proceedings of the Royal Society of Medicine as late as 1927 showed that it was still quite widely used in some situations. 87 Hence it can be argued that Clark was not acting out of the ordinary in 1820-1 when treating Keats in Rome in manner he did.
The question remains however, was Keats treated humanely by Clark when he was under his care in Rome? By January 1821 Clark knew Keats had pulmonary consumption and he showed his humanity by caring for him. He visited Keats regularly, his wife bought food for Keats and Severn and Clark took on responsibility for obtaining funds, since by this stage Severn was nursing Keats virtually on his own and was unable to earn his living as a portrait painter.
Clark's early years as a naval doctor, treating sailors and suffering shipwrecks, could perhaps have made him doctrinaire in his opinions and his approach to patients. On the other hand, rather than incompetence, it has been suggested that Clark's failure to inform patients of their diagnosis was due to compassion, along with a kindly desire to spare their feelings. 88 In Keats situation this is apparent from Clark's letter of 27 November 1820, when diagnosing the disease of his stomach and perhaps his lungs, he cautions 'but say nothing to his friends.' 89 The same suggestion of compassion for his patient has also been made with regard to Dr Bree. 90 Richard Monckton Milnes (1809-1885) wrote in his Letter and Life of John Keats that Keats was very ill in Naples and on arriving in Rome, he sailed: 'The very thing which I want to live most for will be a great occasion of my death. I cannot help it. Who can help it?' 94 From these letters it can be inferred that Keats knew he was dying in the summer of 1820, but he took advice to travel abroad as a possible last hope for a cure. The artist Aubrey Beardsley (1872-98) also suffered from tuberculosis and travelled to France during the last stages of his disease and died in Paris on 16 March 1898. He knew he was dying and without effective treatment at that time he travelled abroad to die.
If Clark had met Keats in London as had been proposed, would he have advised him to travel to Rome in 1820? The answer to this lies in Severn's letter to Taylor dated 25/26 January 1821, when he wrote that the doctor says Keats should never have left England. 95 Certainly by 1836 when Clark wrote his book on pulmonary consumption he would not have done so, perhaps remembering John Keats, when he wrote that the medical advisor should hesitate before sending a patient on a long journey in an advanced stage of pulmonary consumption: 'He arrives in worse condition then when he left his own country, and doomed shortly to add another name to the long and melancholy list of his countrymen who have sought, with pain and suffering, a distant country only to find in it a grave.' 96 We therefore conclude that history has been unkind to James Clark's management of John Keats in Rome. At this point Clark was at an early stage in his medical career and was practising what were then acceptable standards of medicine. After Clark left Italy he published books on the management of patients with consumption and rose to prominence in the British medical establishment. Clark contributed to the overall knowledge on consumption by his evaluation of the benefit of climate on this disease, although he persisted in his belief in the relationship between gastric and bronchial inflammation and the non-contagious nature of tuberculosis, as well as in his advocacy of venesection for treating patients with consumption. However, it should be noted that in more recent times it has been discovered that Mycobacterium tuberculosis requires iron in order to thrive, and bleeding will reduce the body's iron stores, so potentially could be beneficial. 97 It is clear though that Clark used the methods then available in order to manage Keats's consumption. He restricted Keats's diet because of his concern for his gastric dyspepsia believing that the alimentary system needed resting. He advised Keats to undertake exercise, especially horse riding, to improve his wellbeing and perhaps his lung function. Furthermore, he regularly bled Keats in order to reduce his abdominal venous congestion. Clark's letters make it clear he knew Keats had consumption, and that the disorder was advanced by the time he first saw him in November 1820 and then by January 1821 had progressed too far for Clark to manage other than by compassion and empathy.
We would argue that in light of what was then known and what treatment he had available, Clark's management was appropriate and that he was a caring and concerned doctor. It is obvious even today that doctors do not have all the answers for the treatment of diseases. Moreover, the question remains how many of the medical profession today can safely say that the treatment they now advise, and practice, might not indeed be regarded as rubbishy when viewed through the eyes of future generations?