Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

There was a time when I should have despised the sermons of seventeenth and eighteenth century divines, but perhaps it is a sign of advancing age that I no longer do. The sermons are often exceedingly well written and full of sense, even if one does not necessarily share the underlying religious standpoint. If one read only that with which one was in complete agreement, one would read very little.

Joseph Butler (1692 – 1752), Lord Bishop of Durham, was considerable as a philosopher (his most famous dictum being “Everything is what it is, and not another thing,” which is actually more metaphysically profound than might at first appear), and he also wrote memorable sermons. He was a deeply charitable man, and believed in hospitals for the poor: he was the most generous contributor to the founding of an infirmary in Newcastle.

The preface to his Fifteen Sermons opens with words that could hardly be less congenial to the spirit of our age:

…it is scarce possible to avoid judging, in some way or other, of almost everything which offers itself to one’s thoughts…

Personally, I am with Butler there, and against the spirit of the age.

The other sermons are subtle explorations of human psychology, still well worth the reading; while the sixth of his Six Sermons Preached upon Public Occasions, before the Duke of Richmond and the Governors of the London Infirmary for the Relief of Sick and Diseased Persons, Especially Manufacturers and Seamen in Merchant-Service, of 1748, is of surprising contemporary relevance.

For example, he treats of the question of whether those whose illnesses are self-inflicted should be treated on the same basis as those whose illnesses are not. Butler believes that they should be; not surprisingly as a bishop, he uses the argument that “we have divine example for relieving those distresses which are brought upon persons by their own faults.”

But he goes further:

Though the natural miseries which are foreseen to be annexed to a vicious course of life are providentially intended to prevent it… yet those miseries, those natural penalties admit of and receive natural reliefs, no less than any other miseries, which could not have been seen or prevented. Charitable providence then… leads us to relieve, not only such distresses as were unavoidable, but also such as people by their own faults have brought upon themselves.

The example he gives is of the diseases brought on by drunkenness, and not so long ago I was asked by a newspaper to write an article denouncing (which I declined to do) the second liver transplant given to a late drunken footballer.

Butler even deals with the economic problems of health care. The infirmary’s rules stated that “none who are judged to be in an asthmatic, consumptive, or dying condition be admitted on any account whatsoever.” Harsh as these words sound, says Butler, they proceed out of the mouth of Charity itself, for:

Charity pronounces it to be better, that poor creatures, who might receive much ease and relief, should be denied it, if their case does not admit of recovery, rather than that others, whose case does admit of it, be left to perish.

The need to ration is nothing new.

My edition of Butler’s works, incidentally, was edited by W E Gladstone in retirement: hard to imagine a recent Prime Minister on such a task in retirement.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Patrick McGrath (born 1950), the distinguished novelist, is the son of Dr Patrick McGrath (1916 – 1994), Physician Superintendent of Broadmoor Hospital between 1957 and 1981. Alas the latter, though he led a dramatic and varied life, committed very little to paper: not more, he said, than a few occasional medical papers and some letters to The Times. His life story would have been the stuff of legend.

In the first third of his novel Asylum, McGrath gives a lyrical picture of what it was like to grow up in the precincts of an institution for the criminally insane as the son of the superintendent, an upbringing half-prelapsarian and half-sinister. There may be better contemporary prose than this account, but if so I do not know it.

Though not a doctor himself, McGrath junior was clearly marked by the medical environment in which he grew up and absorbed the medical atmosphere for later use in his work. The protagonist of his novel Dr Haggard’s Death is a young registrar in surgery at a London teaching hospital just before the outbreak of the war (when McGrath’s father qualified) who fails to make the grade. His irascible boss, Vincent Cushing, does not think much of him; on one occasion he, Haggard, makes a hash of an appendectomy.

Dr Haggard has a passionate affair with the beautiful wife of the chief pathologist, the arrogant and unsimpático Dr Ratcliff Vaughan, who never manages – or even tries – to rid himself of the smell of cadavers and formalin. When Vaughan discovers the affair, he strikes Haggard across the face at the head of the hospital stairs, down which Vaughan falls and breaks his hip. He cannot reveal what Vaughan has done because to do so would harm his lover. In those days, neither adultery nor divorce were as lightly-regarded as they are now.

Dr Haggard remains in traction for three months: a Smith-Petersen nail is inserted into his femur by his boss, Cushing, who then dismisses him from his service. At the same time Mrs Vaughan brings the affair, the one great love-affair of Haggard’s life, to an end. He has lost everything, and knows that he will never recover from it. Nothing remains to him but general practice in a dispiriting seaside town on the South Coast, where senior civil servants and retired professionals go to die.

Haggard gives a name to the metal rod in his femur: Spike. Spike gives him trouble when the weather is damp and cold, or when disagreeable emotions and memories come to the fore in Haggard’s mind. He then injects himself with morphine; investigated by the Home Office for the practice’s high usage of narcotics, he succeeds in persuading the inspector that it is because of the nature of his patients, who are mostly decrepit or close to death.

On one occasion Haggard tries to defeat the habit by abstention, and there follows the usual exaggerated literary depiction of withdrawal effects from morphine; yet it is only too plausible that Haggard should himself be a victim of the mythology of withdrawal. Altogether, the novel is a sensitive depiction of loss and failure, so much more interesting than that of unbroken success: and more frequently encountered, too.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Xavier de Maistre (1763 – 1852) was the younger brother of the brilliant reactionary philosopher, Joseph de Maistre (1753 – 1821). Both wrote in French, but were actually Piedmontese: Joseph was Sardinian ambassador to St Petersburg while Xavier served the Tsar and died there.

Xavier is now mainly remembered for his amusing Voyage autour de ma chambre (Voyage Round My Bedroom) in which he describes with wit and irony a circumnavigation of his room in forty-two days, stopping off at various points to reflect philosophically on the condition of mankind. For example, he calls his looking-glass the greatest masterpiece of human art because it reflects, and can reflect, nothing but the truth; the only problem is that the prism of amour-propre is the most powerful distorting prism known, far more distorting than that used by Sir Isaac Newton. In other words, we are ready to receive anything except the truth about ourselves.

Xavier wrote little; one of his works was The Leper of the City of Aosta. The protagonist of the story – the leper – is made to live in an abandoned castle in a depopulated area south of the city, where he is provided for by the municipality but is cut off from all human contact for fear of contagion. His sister lived with him for a time, also a leper, but she dies of the disease, leaving him entirely alone – apart, that is, from a dog.

The dog is not a handsome one, but he is affectionate and the leper loves him. From time to time, however, the dog roams and is thought by the nearest inhabitants to be a potential spreader of his master’s disease, so that one day they come to the castle and demand that he deliver the dog up to them so that they can kill him. Initially they want to drown him but finally decide on lapidation. The leper hears the pathetic cries of the dog as he is done to death, and despises himself for not having protected him better as it was his impossible duty to do.

De Maistre here demonstrates his sympathetic understanding of the intense and loving relationship that the lonely and disabled develop with their dogs; his story is strongly reminiscent of Turgenev’s short masterpiece, Mumu, in which a deaf and dumb serf called Gerasim is forced to drown the little dog upon which he pours all the love of his heart for lack of any other object upon which to pour it because his mistress, a capricious and thoroughly spoilt woman, says that the dog’s barking (not very much) has given her a headache. Carlyle wrote that Mumu was the most powerful denunciation of arbitrary power that he had ever read; and if there is a more powerful one, I certainly do not know it.

After the dog dies, the leper thinks of suicide, but even the thought seems to him a terrible crime.

In de Maistre’s story, a sympathetic soldier visits the leper and extends his hand to him, which the leper refuses to take. He does not even agree to epistolary contact between them, for fear of infecting the soldier. Instead he says to him as he takes his leave that he needs no other friend than God, in whom they will eventually be united. ‘Stranger,’ he says, ‘when sorrow or discouragement attack you, think of the hermit of Aosta. You will not then have visited in vain.’

Ah, if only the thought of those who are worse off than ourselves could truly console us as it should!

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Publishers, in my experience, speak as if they had some special insight into the book market; but they are always surprised when a book sells either well or badly. The market is incalculable: who would have guessed that books with titles such as Does Anything Eat Wasps? Or Why Don’t Penguins’ Feet Freeze? would sell so well?

Yet there has long been a taste for arcane and miscellaneous knowledge. John Timbs (1801 – 1875), who once worked as a druggist, spent most of his life catering to the Victorian public’s thirst for facts, or supposed facts, compiling compendia about everything from ghosts to frescoes to electric telegraph cables. One of his most successful works was Things not Generally Known, my copy (1857) being a new edition that claimed to be one of the sixteen thousandth printed.

Among the things not generally known were some of medical interest, for example that epidemic cholera did not add to the overall mortality:

It appears that the total number of deaths in the cholera-year (1849), for all England and Wales, was 440,839; but in 1850 the number of deaths fell to 368,995, being not only 71,844 less than in the cholera-year, but even less than the number of deaths in the year preceding that of cholera, by as many as 30,838.

Averaging the number of deaths in the two pre-cholera years and that of the cholera year and the year following, we find “that no greater number of people died in those years because of the cholera intervening than if the cholera had not visited us.”

Is the moral of this that there was no need to panic, and that those victims of cholera should take consolation from the fact that they would have died anyway without it? Doctors, at any rate, could draw no such happy conclusion: Timbs mentions the fact that during “cholera visitations” between 12 and 20 per cent of “the medical men employed” died. True officers lead from the front.

Published only two years before On the Origin of Species by Means of Natural Selection, Timbs informed his readers that:

The new and brilliant science of geology attests that man was the last of created beings in this planet… she affords conclusive evidence that, as we are told in Scripture, he cannot have occupied the earth longer than six thousand years.

But as for individual humans, their time is short:

The average of Human Life is about 33 years. One quarter die previous to the age of seven years; one half before reaching 17. To every hundred persons, only six reach the age of sixty-five.

For the enlightenment of those lucky six, Timbs turns his attention to the important question of human hair turning grey, and tells the following story of a doctor:

A medical man in London, less than twenty years ago, under the fear of bankruptcy, had his dark hair so changed in the same period that his friends failed to recognise him; but the colour in this instance returned, as his worldly prospects revived.

There is hope for me yet, then; unlike Lady Harbury’s hair, that turned quite gold from grief, mine might (if my investments do well) turn quite brown from prosperity. The colour of my hair depends, then, on the outcome of the crisis.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

The forward to Denton Welch’s last, unfinished, posthumously published novel, A Voice Through a Cloud, is very moving:

The manuscript of this nearly completed novel by Denton Welch was at his bedside when he died at the age of thirty-one. He had suffered thirteen years of chronic and painful illness caused by a road accident in which he sustained a serious fracture of the spine… Towards the end he could work for only three or four minutes at a time… Even then, he made colossal and nearly successful attempts to finish the book. He died on the afternoon of December 30th, 1948, still upheld in his last hours by the high courage which seemed somehow the fruit of his rare intelligence.

Actually, Welch (1915 – 1948), who was also an accomplished painter, was thirty-three when he died. He suffered from Potts disease of the spine as well as the injury; his heroic efforts to remain productive make one ashamed (at least temporarily, while one recalls them) to carp about trivial inconveniences.

The novel is autobiographical, or semi-autobiographical, and the first half at least ought to be given to every medical student to read. There is a graphic account of what it is like to come round after an accident:

Everything about me seemed to be reeling and breaking up. Bright little points glittered all down the front of the liquid man kneeling beside me. I knew at once that he was a policeman, and I thought that in his official capacity, he was performing some ritual operation on me.

Welch observed his own injuries with a detachment that allowed him later to describe them so accurately:

When the nurse touched the flesh of the bruised leg, it yielded in just the way that a wine jelly yields to the pressure of the spoon.

But above all, and most valuably, he describes the petty cruelties and humiliations visited upon him by the nurses, who tell him to try to sleep when he is in severe pain, and to keep quiet when he cries out with pain.

Suddenly, without warning, the nurse gave my body a sharp little jerk which sent such agony though me that I screamed out… The woman, after the first shock of my scream, said: “Oh, I never pinched you! Fancy making all that fuss! I never pinched you!”

This, of course, suggests that the nurse was in the habit of pinching patients.

Later he is moved to a ward in the National Hospital, Queen Square (or so I infer from the description).

One day a specialist was in the ward, examining a patient, when the patient fell down in front of him in a fit. The patient was a fat middle-aged man; he shrieked and trembled and rolled on the floor… It was a terrifying and grotesque sight, but the specialist watched it with a smile on his face. He neither raised the patient up nor prevented him from cutting his head on the corner of the bedside locker.

When the patient recovered consciousness, but was still confused, the specialist said, for all to hear:

Well, I must say there’s one improvement this week – you’re falling so much more gracefully!

And then “he gave a light little well-bred laugh.”

Students should read the book because a bad example is a very good example.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

One of the principal questions to be asked about heroes is how long it will take before they are shown to have feet of clay. In the case of Major Claude Eatherly, it did not take long to show that it was not his feet alone that were of clay: but in the meantime, philosophers such as Gunther Anders and Bertrand Russell swallowed the myth in its entirety.

Eatherly was a major in the US Air Force who flew the B29 bomber that checked that the weather was clear for the bombing of Hiroshima. He neither dropped the bomb nor saw the explosion, nor did he take part in the mission to bomb Nagasaki.

After the war, he flew a mission to Bikini to measure the radioactivity in the atmosphere. After that, he was disappointed not to be commissioned permanently as a pilot; and because of his misconduct he was lucky to escape dishonourable discharge. The evidence is that he was disappointed not to have been selected for the actual bombing of Hiroshima, Nagasaki and Bikini; he was bitterly disappointed not to be commissioned.

Once he left the Air Force, he drifted; he was unfaithful to his wife and was neglectful of his children; he began to drink; in 1947 he involved himself in illegal gun-running to Cuba, whose capital, Havana, he agreed to bomb preparatory to a coup d’etat for a fee of $100,000 (he and his associates were arrested before any of this could take place); he passed forged cheques and finally indulged in armed robbery.

It was then, thanks to a story written in Newsweek in 1957, that a myth emerged and rang round the world: Major Eatherly had committed his crimes because of something his psychiatrist called a ‘guilt complex;’ Eatherly had so bitterly repented bombing Hiroshima that he committed crimes in order to be caught and punished for his role in the killing of tens of thousands. The Austrian philosopher, Gunther Anders, wrote to him and their correspondence was published in many languages. Eatherly became almost a sainted figure, a martyr to the cause of world peace.

The inaccuracy of the myth was brilliantly exposed by an American journalist and novelist called William Bradford Huie (1910 – 1986). The unwitting originator of it was Dr Oleinick Pavlovitch Constantine (1908 – 1983), a psychiatrist with the Veterans’ Administration in Waco, Texas, who knew practically nothing of Eatherly’s previous history, and believed the highly selective, dramatised and exaggerated account that Eatherly gave him in 1956. It was he who relayed the theory of the guilt complex to a law court, from which it spread round the world.

Dr Constantine was not Eatherly’s first psychiatrist. When Eatherly was arrested for his various crimes, he often (and successfully) tried to get himself admitted to psychiatric hospital to avoid imprisonment. There is no evidence, though, that he was ever mad or even highly disturbed; nevertheless, he was on one occasion given a great deal of insulin coma therapy. He was also an early recipient of chlorpromazine, given illogically in conjunction with methylphenidate.

The world believed Dr Constantine’s theory because it wanted to do so; it paid no attention to the opinion of another psychiatrist, Dr Ross, who knew Eatherly much better than Constantine:

This patient has no moral feelings toward his wife or children, or toward any human being that he comes in contact with. He has no feeling or responsibility or moral obligation to an individual or group or to society as a whole.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Bernard de Mandeville (1670 – 1733) was a Dutch doctor who studied at Leiden but practised in England, whither he emigrated when some of his poems incited a riot in Rotterdam. He became a master of English prose and one of the most important political philosophers of his age.

Among his lesser works were a defence of brothels – A Modest Defence of the Public Stews: or, an Essay Upon Whoring, as it Is now practis’d in these Kingdoms – and a proposal for making public executions more efficacious in the deterrence of crime, An Enquiry Into the Causes of the Frequent Public Executions at Tyburn. He is most famous, however, for his Fable of the Bees, in which he presents arguments that private vices become public virtues, and that no country can thrive on the basis of behaviour deemed moral.

One is never quite sure how literally to take what Mandeville writes, but there is little doubt about the contempt in which he hold his medical colleagues in his A Treatise of the Hypochondriack and Hysterick Passions. This is written in the form of a dialogue, mainly between Philopirio (lover of experience) and Misomedon (hater of physic), the former a doctor who is to be taken as Mandeville himself, the latter a depressed patient. Much of the bile poured on the medical profession is from Mesomedon, but since Philopirio does not contradict him, and when he speaks holds to essentially the same view, it can be assumed that it represents Mandeville’s opinion.

Philopirio describes how to be a successful physician:

If you can Chat, or be a Good Companion, you may drink your self into Practice; but if you are too dull for what I have hitherto named, you must say little and be Civil to all the World, observe your certain Hours, and take care you are often sent for were you are, and as’d for where you are not; but tho’ in Coffee-houses you are forc’d to sit idle and loiter away your Time all day long, yet when our of ’em always Counterfeit a Man that is in haste, and wanted in a great many Places… contradict no body, never open your Lips without a Smile, and give no Peace to your Hat.

In other words, it is all a question of acting and not of curing, even if the latter were possible. But, even more scandalously, Mesomedon says that doctors do not want to save their patients:

But among the Crafty and Polite [physicians], that in reality mind nothing but themselves and getting Money, there is no Appearance of [wanting to cure their patients]… Shall I Hazard my Reputation, say they, on the possibility of saving a Patient, when I may be sure of preserving it as well when he dies as when he lives? Nay it is certain, that should a Patient miscarry after a daring Medicine, a great Clamour would be rais’d against the Physician by his Enemies. No wise Man ought knowingly to lay himself open to the Censures of a malicious World, and therefore to prescribe otherwise, than in the safe common Road, is what a Man cannot answer to his family.

It has been suggested that Mandeville was motivated by envy and his own lack of financial success as a physician. But he was an early believer in the work-life balance. Philopirio dislikes working too hard, seeing too many patients, or hurrying.

Not that I love to be idle; but I want to be employed to my own liking.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Prophecy is a fool’s game, which perhaps is why so many of us indulge in it. In 1924 Bertrand Russell wrote a very short book called Icarus or the Future of Science, a response to J.B.S. Haldane’s Daedalus or the Science of the Future. Daedalus, you remember, gave the power of flight to Icarus, and we all know what happened to him (oddly enough, the Brazilian airline Varig once unadvisedly called its in-flight magazine Icarus).

Haldane painted a rosy future for mankind thanks to its increased control over nature; Russell was more pessimistic. He thought American domination of the whole world was the best that we could hope for, next to the complete collapse of our civilization which, he said, ‘would in the end be preferable to this alternative.’

Russell divides the sciences into two, the physical and the anthropological, of which medicine is much the most important. He believes (correctly, as it now turns out) that ‘the study of heredity may in time make eugenics an exact science, and perhaps we shall in a later age be able to determine at will the sex of our children.’ Though no monogamist himself, he was not altogether sanguine about the results: ‘This would probably lead to an excess of males, involving a complete change in family institutions.’

He sees the march of birth control as inevitable. Opposition to it comes from superstition and the desire of employers to have enough people to keep wages low. However, not all the effects of birth control are to his taste. ‘Before long the population may actually diminish. This is already happening in the most intelligent sections of the most intelligent nations… before long, birth-control may become nearly universal among the white races; it will then not deteriorate their quality, but only diminish their numbers, at a time when uncivilized races are still prolific and are preserved from a high death-rate by white science.’

The other problem is the ductless glands:

More sensational than tests of intelligence is the possibility of controlling the emotional life through the secretions of the ductless glands. It will be possible to make people choleric or timid, strongly or weakly sexed, and so on, as may be desired. Differences of emotional disposition seem to be chiefly due to secretions of the ductless glands, and therefore controllable by injections or by increasing or diminishing secretions.

The politically powerful will inject the masses to make them docile. But if it is not the ductless glands that will give the powerful this control over the masses, it will be some other technology:

We shall have the emotions desired by our rulers, and the chief business of elementary education will be to produce the required disposition, no longer by punishment or moral precept, but by the far surer method of injection or diet.

Of course, the main emotional disposition required has turned out to be not docility, but self-esteem.

Russell foresaw the end of physical want, thanks to the application of science, but luckily we are different from the animals.

Wolves in a state of nature have difficulty in getting food, and therefore need the stimulus of a very insistent hunger. The result is that their descendants, domestic dogs, over-eat if they are allowed to do so.

But because of our difference from the beasts ‘over-eating is not a serious danger.’

As I said, prophecy is a fool’s game.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

The narrator of the novel Lost Horizon is a neurologist who has written a book on amnesia, which is one of the reasons why the story of Conway interests him. Conway, a veteran of the trench warfare of the First World War, is a British consul in Afghanistan who disappears and finds peace in Shangri-La, a Tibetan lamissary, where the secret of the good life has been found and as a consequence that of longevity also. When he leaves Shangri-La, however, he loses his memory, recovers it briefly to recount his story, and then loses it again.

The author of Lost Horizon was James Hilton (1900 – 1954) and his book gave not only a name but a whole concept to the English-speaking world. Strangely enough, he appended a dateline to it: Woodford Green (Oak Hill Gardens, to be exact), 1933. This raises the interesting question of whether there are people in Shangri-La (or rather, Shangri-La-like places) dreaming of semi-detached houses in Woodford Green.

Lost Horizon was not really a success until after the publication of Goodbye, Mr Chips a year later: both were then publishing phenomena, it often being said that Lost Horizon was the first mass-market paperback best-seller in the United States.

Mr Chips – short for Chipping – is a school-master aged 85. He was a teacher at Brookfield School for sixty-three years until his retirement in 1913, when he went into lodgings near the school. He looks back on his life as he dozes in his chair:

When you are getting on in years (but not ill, of course), you get very sleepy at times, and the hours seem to pass like lazy cattle moving across a landscape.

His doctor, Merivale, visits him every fortnight or so and drinks a glass of sherry with him. Dr Merivale is the epitome of the reassuring family doctor:

My dear fellow, you’re fitter than I am. You’re past the age when people get these horrible diseases; you’re one of the few lucky ones who’re going to die a really natural death. That is, of course, if you die at all.

By natural death, I suppose, he means old age, terminal decay, rather than anything like cancer or heart attack; but this jocular reassurance is immediately belied by what he tells Mr Chips’ landlady on his way out:

Look after him, you know. His chest… it puts a strain on his heart.

The puritan modern sensibility would no doubt find this disjunction between what the doctor says to the patient and what he says to the person looking after him shocking, but I am not certain that it is inhumane.

Illness quietly pervades the book. An outbreak of German measles – German measles, who can remember it? – affects half the school and turns much of it into a hospital ward. Everyone thinks of Mr Chips as a confirmed bachelor, but in fact he was once, briefly, married. In 1898, his beloved wife died in childbirth, along with the child, presumably of a prolonged labour. In 1916, Chatteris, the headmaster in his late thirties, and who looks very ill, confides guiltily in Mr Chips, who is now retired, that he, Chatteris, is indeed ill. He has diabetes.

Chatteris fell ill during the winter of ’17… Then in April, [he] died.

Without intending to, Hilton reminds us of how far we have come, medically. Will our own best-selling authors do the same for our descendants?