by Stephen Wade
Few people in the 1860s gave a second thought to the possibility that animals were a source of terrible disease. In the towns the horses were present in thousands, and in the country, cattle, sheep and horses were part of a dozen everyday tasks, integral to life, as they had been for centuries. No-one even vaguely considered that they were dangerous to man, except in the case of cow-pox, and that had been understood and dealt with after Jenner’s development of vaccination.
In fact, as public health inspections had shown in Carmarthen after the horrendous outbreak of cholera a few decades before Sarah’s case, animals, along with sewage and water supplies, were inextricably mixed in with factors determining some diseases which were zoonotic in nature, and were stealthily creeping into the danger areas of daily working lives. If we add to that the lack of awareness of the importance of domestic hygiene, we have something disastrous latent among the working classes in particular.
We now have a much deeper knowledge of these things, and since 1976 an infection labelled human cryptosporidiosis has been defined and isolated. Cryptosporidium was identified in 1907 by a researcher called Tyzzer when he studied the intestines of mice; it develops in epithelial cells (those which cover the external tissues of the body and of organs) and infects the small intestines of mammals – and of people. It is a protozoa, an entity whose existence was far beyond the knowledge any medical man had in 1869.
Two important features of this condition stand out in the context of Sarah’s illness and her reported behaviour. First, it is active in those who are ‘immunocompromised’ – that is, in Sarah’s case, her condition as she came out of the scarlet fever episode. At that point, she was susceptible to further infection. Secondly, it damages the little sacs in the epithelium of the intestine and impairs digestion and the absorption of nutrients. In other words, it can be the cause of weight loss, reducing the effects of food taken, which would not be absorbed, but remain in the gut.
The symptoms which would have been observable if Sarah had contracted this shortly after the scarlet fever, would have been nausea and a lack of appetite, with diarrhoea and a watery stool; anorexia and abdominal pain can persist, and the illness may remain long after the incubation period of around two weeks. So, after going to school for a while in early 1867, following the scarlet fever, she became ill again for some weeks, then the anorexic behaviour began and intensified. A case study of an outbreak of cryptosporidium in North Humberside in 1989 found that the main symptoms were diarrhoea, loss of appetite, abdominal pain and loss of weight and nausea.
Research has shown that the disease is life-threatening in those who are immunocompromised. As to clear signs which would be apparent at an autopsy, the small bowel would have a mucous infection which, as R.L. Coop and others have found, ‘may extend throughout the intestinal tract’. Note that Lewis found the mucous fluid also in the ileum – the smallest part of the small intestine. It is certain that some kind of problem with the digestive tract was evident, yet many diseases we now know of would not have been apparent at autopsy. Both doctors said that all Sarah’s organs appeared to be healthy, but pointers towards a presence of cryptosporidium would not have been evident without modern microscopic Lewis and Davies were nonplussed by the mucous fluid, and there was no suggestion given by either as to what this grumous fluid was.
In a more everyday context, it would make obvious sense that Sarah would not want to eat, when the result was horrendous diarrhoea and nausea. The ‘fits’ and the supposed pain down one side may well have been centred in the abdomen, where the ‘rumblings’ were heard by doctors, most vividly expressed by Dr Fowler.
We can imagine Sarah stealing through the servant’s room next door, and into the dairy for some milk or flummery, which may or may not have been kept in a bottle that went beneath her arm. If it did, then that would make it possible to take food at almost any time, rather than a quick raid as a night feeder, as Fowler surmised.
If this was the case, and Sarah had an infection of this zoonotic illness, then after the initial weight loss (which would not be much, and only for a short period) she would eat and drink, but sparingly. Given that she was bed-ridden, with very few calories burned, she would have maintained that fleshy, healthy appearance all through the period in question, with the real illness being down inside her digestive tract, something that would have made the idea of solid food most unattractive. For that reason, the spoon food referred to – something that could be bottled – seems to be the most likely nourishment.
We know that Evan’s 120 acres of land included cattle, and that these were stalled at one end of the long house, with the main bedroom at the other end; we also know that she was taking small quantities of milk, rice and flummery until August, 1867. It is reasonable to assume that this diet was continued as she night-fed, and that she contracted some disease in that early phase; there is a possibility that the disease in question was zoonotic, and perhaps specifically cryptosporidium parvum.
This was a time when human communities were living day to day in extreme proximity to their animals. In the case of a dairy farmer, it is obvious that, Welsh social history being a story of men and animals under the roofs of various types of houses and cottages, there would be maximum opportunity for disease to transfer from beast to man. In fact, the circumstances at Lletherneuadd strongly suggest that of all the family members, the night-feeder Sarah was the one who would have most access to dairy produce, eating as she surely did, secretly and as often as she liked, either while the household slept, or as they were all in the fields or busily engaged in chores.
My reading of the facts of the case makes this the most persuasive explanation of the mystery illness that afflicted her; and I feel confident that Dr Fowler, the first hard-headed medical man to look closely at Sarah, was correct in his suggestion that she could and did feed when she wanted, within the time frame of opportunities she had. Another perspective on this is that, with the idea of family collusion in mind, the eating would be part of the game, subsequently eclipsed by the more appealing business of the display, the bright girl on the bed, reading aloud and defying nature. Undoubtedly, there was a pride in the parents in seeing their girl, well-read and articulate, talking to strangers, alert and vibrant at least some of the time, while all the while the strangers and visitors from far and wide must have been assessing her condition, noting the fact that she had flesh and was certainly not emaciated, as perhaps their reading about the old saints and hermits suggested she should look. Some of the visitors must have chatted excitedly, on their long train journey to Carmarthenshire, about what they were going to see – and many would have described a ‘freak of nature’ rather than the person they saw, waiting for them bedecked and ritualised.
Of course, we will never know for sure, and there remains the question of Sarah’s hysteria or other related mental illness. We must explore her sickness in relation to the family, as well as to what can easily be labelled hysteria but may well be something far more familiar. Surely it is less vague and undefined to accept that the calves under the roof at the long house were more of an immediate threat to health – on a serious level – than the usual reference to the established diseases of childhood, most of which were dealt with by rest, food and drink, and some cosseting.
It is a speculation, but one in which there are modern parallels which compel our attention: a tiny invader of the small intestine would evince all the symptoms the doctors heard and guessed at. Yet, looking at the way the illness invaded those who were already afflicted by a sickness, it would account for the prolonged digestive troubles the little girl suffered.
Sometimes, the detective work done on the past has to pay attention to influences and possibilities which provide an answer, and leave the spaces for obvious objections there for future writers and readers to deal with. I find the potential for the zoonotic illness in Sarah to be very hard to resist in the face of so many dead ends in the thinking about the known diseases of her time which ravaged the Victorian ch
ildren. We have to ask: what was the basis of her staple diet? The answer is dairy products, at a time when diseases carried in such foods were not identified nor understood.
8
So What Was Wrong with Sarah? Hysteria and Collusion
Collusion …is a game played by two or more people
whereby they deceive themselves…
R.D. Laing: Self and Others.
In 1869 the human mind was still as unexplored as the vast interior of Africa. It was an age when phrenologists were taken seriously, when they suggested that a part of the head was where certain emotions lay, and that bumps on the head indicated defined predispositions and temperaments. These swellings were believed to be caused by the size of the various areas within the brain which corresponded to certain faculties. It was also the age in which many believed in physiognomy as a pointer to mental states; twenty years after Sarah’s death, Cesare Lombroso published his Delinquent Man in which he pictured and described the typical features of robbers, burglars and deviants of all kinds.
Administering medicine to the mind had been a topic of public debate in the fairly recent past, when George III had been treated and cured of his madness by Dr Wills of Lincolnshire, and it was generally known that his treatment did not involve such things as drugs, surgery or anything extreme. That is, a ‘moral’ method had brought results with one of the most famous madmen of the century, so surely, many would have thought, the fight to understand the diseased mind could be won? But as the century wore on, when specialisms in medicine began to be established, in a sense there was more confusion.
In such a context, how could mind doctors be taken seriously? The answer is that not many were. We only have to look at the way poets and writers such as John Clare and Charles and Mary Lamb were treated; today they would have been classified in various ways, as being on the manic depressive spectrum. Yet, since the arrival of the revolutionary treatments of mental illness at the beginning of the nineteenth century, there had been few advances. Even by the end of the century, experts were still unsure about the nature of mental illness, and the battle was on to arrive at satisfactory causal explanations. If we consider Sarah and her family with this area of knowledge in mind, we have to leap over time and try to see what they might have been, or have not been, within their time and place.
Bearing the subject of psychiatry in mind, and how the vocabulary of naming and defining mental illness too a long time to develop its nosology, whereby specific conditions were named in a supposedly exact taxonomy, it was not until the last years of the nineteenth century that real progress was made. But is it possible that Sarah was playing mind-games or was in fact in the grip of a psychosis?
When Emil Kraepelin argued that there were two principal descriptors of mental illness, dementia praecox and manic depressive psychosis, he was taking the first steps in separating schizophrenia from other, more scattered and elusive states. Dementia praecox was schizophrenia, and the other depressive state covered an almost infinite number of conditions, many of which we now define and isolate in different forms. But the problem was (and still is) in the nosology – the putting of a name to a supposed illness and the acceptance that this will be challenged and modified. In 1869, blanket terms were accepted, as with ‘hysteria’.
With this in mind, the question arises: it is possible to define and describe aspects of Sarah’s condition and behaviour in psychological terms? If so, are these arguments likely to be more convincing than the physiological ones? The conclusion of the previous chapter was that there are many possibilities, and that I have chosen my own interpretation, offering a possible explanation of what she suffered. I offer no certainty in that, but I hope that my reasoning opens up some debate.
However, my thinking so far has been leading up to an arguably much more convincing explanation, and for this to be developed, we need to return to the subject of hysteria, and to something much more recent in its formulation. It relates to the fact that what is a neurosis to one doctor is a performance to another. If the hysteric simulates feeling, then what I am to suggest goes a step further. For this, we return to the subject of being the centre of attention – yet again.
In 1864, the Religious Tract Society publication, Sunday at Home, had an account of the Hospital for Sick Children which included this passage about the writer’s visit there:
Then I went up a wide staircase, and thought of the happy children who had raced up and down here years ago… The nurse opened a door into a large, lofty room with folding doors. It looked so cheerful, with bright fires, and the panelling of the walls prettily painted. There were clean little beds, each having a convenient sliding tray, which would hold breakfast, books or play things.
There may have been formidable images of hospitals – not far removed in some minds from the dreaded workhouses – but accounts like this, the propaganda of sickness, made bed seem like fun. In fact being in bed could be a place of power, something to exploit, maximise, even make into a special role in the family: the valetudinarian was the usual word when applied to the rich, but for ordinary folk, the person bed-ridden was marked out for special treatment. The reasons why are manifold – sometimes pity, sometimes despair, but also, at times, a sort of triumph in adversity, as with the ‘Good Death’ phenomenon.
Being ill and bed-ridden was, for some, a potential vocation, a career choice. That may sound reductive and callous, but we have the perfect template for this in the life of Elizabeth Barrett Browning, who suffered from an ailment which was never defined and understood, although she did have an accident later in life which added to her frail condition. Elizabeth, thirty years before Sarah Jacob, was in her bed, confined to constant care at Hope End, a house at Led during which time she was writing poems and studying Greek. But of course she was from the wealthy middle class, and her father sent her to be cared for by several celebrated doctors of the day, though all to no avail. Popular culture has placed her in a bed or on a sofa, a delicate soul, visited by her future husband, the poet Robert Browning. She even wrote a poem imagining dying in bed with no-one beside her. This description is not a criticism: she was genuinely ill. My point is that, once the bed and its attendant rituals and almost reverential status is attained, other things may change radically.
As far as the medical men were concerned, their patient at Lletherneuadd was confined to bed and hysterical. Hysteria, as discussed in chapter 2, persisted through the century, and was also one of the areas of interest of Sigmund Freud. By the early twentieth century, when psychological medicine was within the accepted canon of medical knowledge and practice (with Kraepelin’s nomenclature to help), hysteria was described alongside psychoneuroses, so that, for instance, after 1918 and the end of the Great War, it was listed in reference works with ‘shell shock’ and neuroses sometimes linked to the endocrine glands. But hysteria was considered with regard to the emotional experience of sufferers: essentially, the conclusion was that the illness was to be placed in a category of dramatic fantasy. The text books recorded that the ‘emotions of the hysterics are for the most part artificial’ and examples were published such as this one in the 1923 Medical Annual:
One young soldier suffering from an hysterical contracture of the foot broke down during an examination; tears rolled down his cheeks; he addressed his dead brother in language savouring of a South London melodrama; he asked why he himself had not been killed… and all the time, whilst he wailed and wept, the spot of light from the galvanometer remained steady…
Of course, the poor man was under electrotherapy at the time, that treatment being accepted, and we have to note that the writer was not taking seriously any of the emotional expression. The conclusion was that ‘hysterical behaviour is purely imitative’. That thinking is essentially the same as the work of Charcot a century before, at the Salpetriere hospital in Paris, when he would have his ‘hysterical’ women patients parade themselves in front of students and visitors as they enacted emotional states, very much like a drama skills worksh
op. Freud was present at this, and learned a lot from Charcot. But conclusions are hard to draw about whether or not early twentieth century understanding of this kind of illness was any kind of advance. On the surface, it does not seem so at all.
In this context, it is easy to see how Sarah’s illness and symptoms were seen as typical hysteria. Freud’s influence engendered a variety known as dissociative hysteria, and to follow that path the historian needs to bring in speculation of extreme traumatic matters within the subject’s family and peers, and there is no evidence of anything of this in Sarah’s case.
However, there is something else in the family situation of Sarah Jacob, and this relates to Evan and herself. The lawyers and doctors identified one fairly clear aspect of the situation in the family: that Evan Jacob was always wanting to control matters, and that most of what he said hinted at an imposture. The professionals also saw that Sarah was not a victim but knew of the tricks being played. For all this to go so sadly wrong that the girl died is beyond comprehension if we simply keep to those facts. Digging a little deeper, we find something in family dynamics which we now understand very well, but which was then a matter without any vocabulary and out of the region of understanding of the medical mind. At this time, the mind doctors were ‘alienists’ treading unknown territory and out of their depth when it came to treatment. It was the age of experiment, with such topics as hypnotism filling the news pages. Franz Mesmer, who died in 1815, was to leave a legacy of ‘animal magnetism’ which would still be thrilling readers of popular periodicals in the 1890s. Freud and his peers had no impact on Britain until the early twentieth century so in 1869 there was nothing more subtle to explain what might be happening in the Jacob family that such a bizarre and seemingly supernatural event was taking place.