Strange? What could be more typical than a young man, wasted, feverish, racked with cough and hemoptyses—dying? Indeed, the very picture evokes the popular image of some romantic poets of the 19th Century; Keats's tragic death at the age of 25 contributed to that image. So what can be strange in the case of Keats? That John Keats died of tuberculosis is not in doubt, but even with the advantage of almost 200 years of scientific advances—Koch's discovery of the pathogenic bacillus in 1882, the introduction of radiography in 1895, and the introduction of effective chemotherapy and useful vaccines, all of which have led to a fuller and better understanding of the disease process—there still remain some curious, even anomalous features in the presentation and the course of John Keats's tuberculosis. The time sequence is crucial in this case, as it is in the elucidation of any difficult infection. In the month of May in 1817, Keats was in Hampstead with his brothers Tom and George. John, almost 22 years old, appeared to be in excellent health and in good spirits, despite the fact that Tom seemed vaguely unwell and that he was concerned for George, who was soon to marry and to emigrate to the United Sates. Almost a year earlier, John had completed his medical studies at the combined hospitals of Guy's and St. Thomas's and had successfully acquired his Licentiate of the Society of Apothecaries, giving him the approximate status of a contemporary medical family practitioner. Despite these successes, John took a firm decision to leave medicine and to try his hand at poetry.

There is no doubt that medical training, demanding enough at any time, was distressing and even harrowing in the days of uncontrolled sepsis and surgery without anesthesia. These experiences of medical life left in the young poet a substratum of impressions, seldom overt, but which do occasionally surface in his writing. He startled his guardian, Richard Abbey, a successful city man, when, shortly after 21st birthday, Abbey enquired what he intended to do. “I mean to rely on my abilities as a poet,” declared Keats. “You are either mad or a fool to talk in so absurd a manner,” replied Abbey. “My mind is made up,” said John very quietly [1, p. 98]. Keats never practiced medicine.

The first indication we have that all was not well occurred on 8 October 1817, when Keats wrote to his friend Benjamin Bailey after a visit to Oxford, “The little Mercury I have taken has corrected the Poison and improved my Health.” This has led to a great deal of speculation, for in the 19th Century, mercury was used to treat a wide variety of maladies, such as rheumatism, croup, dysentery, and even pulmonary tuberculosis. It has not escaped Keats's biographers that mercury was perhaps most often used in the treatment of venereal disease, and both syphilis and gonorrhea have been suggested as the explanation for the use of “little Mercury” [1, p. 499]. There is, however, no conclusive evidence that Keats had venereal disease. Just over a month later (22 November), in a second letter to Bailey, there occurs another opaque passage: “I think Jane or Marianne has a better opinion of me than I deserve—for really and truly I do not think my Brothers illness connected with mine.” In distancing himself from Tom's illness, Keats was merely saying in code, “I'm not like Tom—suffering from lovesickness.” However, poor Tom's real illness was about to declare itself in no uncertain way—hemoptysis.

However one interprets these rather tenuous data in Keats's case history, one fact is clear: he remained healthy, or at least symptom free, for almost 2 years after these events. In June 1818, with his friend Charles Armitage Brown, Keats undertook an arduous walking tour of northern England and Scotland, with a short detour into Northern Ireland. The physical demands of this ambitious excursion, involving something like 3200 km, including climbing Ben Nevis—some 1400 m—would have been taxing enough for anyone [2]. After perhaps two-thirds of the tour, while on the island of Mull, Keats complained of a sore throat; as Brown subsequently explained, “For some time he had been annoyed by a slight inflammation of the throat, occasioned by rainy days, fatigue, privation.” He consulted a physician and was advised to rest, but after a few days, he undertook the ascent of Ben Nevis.

The walking tour of Scotland is a turning point in dividing Keats scholars into those who believe that it was before his walking tour that Keats acquired tuberculosis, during contact while nursing his brother Tom in the close confines of his Hampstead room, and those who consider that the walking tour left him permanently vulnerable; as Carol Walker puts it, “His condition was never quite the same afterwards. His defences were permanently down” [2].

It is not very fruitful to try to pinpoint when Keats might have acquired his infection, and the walking tour “watershed” may be irrelevant. At that time, tuberculosis was so prevalent in the community, and the Keats family was to lose not only John, but also his 2 brothers, Tom and George, as well as their mother and uncle, to this disease. Therefore, the opportunities to acquire infection were so commonplace as to defy plausible—never mind accurate—prediction of its source. But there was a watershed for Keats himself: the walking tour represents a break with the past—the past, which includes the period of his medical training, followed by the anxiety and uncertainty of the decision to renounce medicine—while the tour itself offered a host of new experiences from a much wider provenance, from a much broader horizon than he was accustomed to. From henceforth was a new beginning; he would devote his life to poetry.

Despite the trauma of Tom's death, the psychological blow of the wretched reviews of his early poems in Blackwood's Edinburgh Magazine, and his parlous financial state, Keats's health seemed remarkably good. Certainly, this is true until September 1818. However, the sore throats continued; they were often persistent but apparently never very severe. Biographers of Keats have varied in their interpretation of this symptom: multiple attacks of simple catarrhal tonsillitis, syphilitic ulceration, effects of mercury ingestion, or the onset of tuberculosis. Some have suggested that the “sore throats” were in fact laryngeal tuberculosis. One might ask, perhaps, why should Keats biographers necessarily have a meaningful opinion on such medical minutiae? We have, at least, a partial answer to that question, because one of Keats's biographers, Amy Lowell, was so concerned by the complexity of the medical data that she consulted a specialist physician and published his report [3].

Amy Lowell [3] was one of the first of a long line of distinguished American biographers of Keats. She published her 2-volume book John Keats in 1925. She chose Dr. John B. Hawes the second, the Chief of the Pulmonary Clinic (Massachusetts General Hospital), who had been formerly the Secretary of the Tuberculosis Board of Massachusetts, and compiled for him a history of Keats's health that seems to have been a comprehensive document. Here is Dr. Hawes's assessment, as given in Lowell's biography:

I have been over Miss Lowell's manuscript giving the history of Keats's life and death and I can say in checking it up, it is not inconsistent with pulmonary tuberculosis and, laryngeal tuberculosis. Although not typical of the latter, I have seen not a few cases of laryngeal tuberculosis that have acted in just the way this one has done. There have been periods when the throat condition has been very severe with hoarseness, and pain, and for some unknown reason there would be equal periods when practically all symptoms would disappear except a slight hoarseness. While syphilis, therefore, may have been a factor in this case, I do not feel such would necessarily be the case, but I do feel that tuberculosis would explain everything.

Lowell also consulted Dr. Abner Post, Professor Emeritus of Syphilis at Harvard Medical School. Keeping these expert opinions in mind, Lowell gave her view “that although it is possible that Keats did contract syphilis, there is no proof whatsoever that he did, since his symptoms, so far as we can tell, are perfectly attributable to tuberculosis alone.” Leaving aside the question of syphilis, which is almost certainly not relevant, Dr. Hawes's conclusion that tuberculosis was the diagnosis is consistent with everything that we can know about Keats's illness. What is extraordinary, however, is the emphasis he gives to the likelihood of laryngeal tuberculosis. Laryngeal tuberculosis is usually secondary to gross pulmonary disease, so that symptoms relating to laryngeal involvement would be surprising as a presenting feature of disease. In rare instances, laryngeal tuberculosis just might be an early feature of disease; furthermore, as Dr. Hawes suggested, laryngeal symptoms may have a curious fluctuating course. However, those symptoms must include laryngeal not pharyngeal pain or discomfort, as well as hoarseness. Keats had qualified in medicine and must have been quite well aware of the difference between laryngeal and pharyngeal complaints. But did Keats complain of hoarseness? Lord Brock, a distinguished surgeon who discussed Keats's illness in his Sydenham lecture of 1971 [4], was obviously concerned about the diagnosis of laryngeal tuberculosis, although he does not mention Dr. Hawes's assessment. Brock notes that Keats complained of sore throats in February, June, and December of 1819 and suggests that these episodes were of a catarrhal nature. Moreover, Brock went through the whole account of Keats's illness and was able to find only 1 transient complaint of hoarseness, and that was in September 1820, when Keats and Joseph Severn boarded a ship to sail to Naples. Brock concluded his assessment, “There is no mention of hoarseness, loss of voice, pain on swallowing or pain in the larynx itself.”

An autopsy was performed 2 days after Keats died in Rome (23 February 1821). This was performed by Dr. James Clark, the personal physician who had looked after Keats during his time in Rome, who was assisted by an Italian surgeon and another doctor. This examination, from the scant accounts we have of it, appears to have been of a very limited nature, probably confined to the thorax; he noted that “the lungs were completely gone” [5]. We have no information on the state of other organs and no mention of the larynx or abdominal organs that might have been affected by disease. No formal autopsy report exists, because it is almost certain that none was made.

At the beginning of 1820, Keats lived in Hampstead with his friend Charles Brown; the house they were sharing was called “Wentworth Place” (now called “Keats House”). During the previous year (1819), Keats had shown an extraordinary burst of magnificent poetic invention. To this period belongs the writing of the superb quartet of famous odes, including “Ode to a Nightingale.” He had also been able to develop something of a social life and to enjoy the pleasures of London. On 3 February 1820, he traveled from town, sitting on the outside of the coach to save money, and, perhaps foolishly, he had left off his coat. He got off the coach at the top of Pond Street and stumbled into Wentworth Place at about 11:00 P.M. Brown did not like the look of him, thought that he might have been drinking, for he looked ill, and advised him to go to bed immediately. Brown went to Keats's room with a glass of spirits, and, as he was getting into bed, Keats coughed and a small spot of blood appeared on the sheet. Brown heard him say, “That is blood from my mouth, bring me the candle Brown, let me see this blood.” And then, looking up at Brown, he 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.” And, indeed, how accurate he was in diagnosis and prognosis, for he died in Rome just over a year later.

That year was the history of uncontrolled phthisis—multiple hemoptyses and bouts of fever, sweats, and wasting—indeed, he had classical consumption. The picture is all too typical; there is nothing strange or enigmatic about this terminal year of Keats's terrible suffering.

Keats went to Rome with his good friend Joseph Severn in the forlorn hope of cure, enduring a nightmare journey in which Keats shared a cabin with a young woman who was in an even more advanced stage of consumption than was Keats himself.

The physician chosen to attend Keats in Rome was James Clark, later Sir James Clark. He had trained in Edinburgh, obtained his doctor of medicine degree in 1817, and, 2 years later, settled in Rome, where there was a sizeable English community. He became interested in the effects of climate on consumption and published a book on pulmonary consumption. He acquired the new diagnostic aid of the time, Laennec's stethoscope, which he may have used to examine Keats. Dr. Clark became a well-known physician in the English colony in Rome and eventually was appointed first physician to Queen Victoria and became an esteemed friend of Prince Albert. Dr. Clark, who had obtained rooms for Severn and Keats at the Spanish Steps, saw Keats at his arrival and was in close attendance until Keats died ∼6 months later.

It is interesting to note that this able physician, who had a special interest in consumption, reported a slightly unusual, even bizarre aspect of Keats's tuberculosis. His initial assessment of Keats's condition makes little mention of disease of the lungs, noting that “the chief part of his disease so far as I can see seems to be seated in his stomach. I have some suspicion of the disease of the heart and it may be of the lungs ... if I can put his mind at rest I think he'll do well.” Lord Brock, with surgical directness or even arrogance, does not think very much of this conclusion:

Even for 1820 this was a very poor assessment of Keats's illness and, however able Clark was later, it is clear that he was medically poor just then. It is difficult to criticise doctors in the generally backward state of medical knowledge then, but even, in the absence of a stethoscope it is difficult to condone such a rubbishy assessment [4].

Perhaps, by way of extenuation, one might add, in Clark's favor, that we have no idea what passed between patient and physician by way of conversation, complaint, or history during that first fateful consultation. And, of course, we have all made—and continue to make—mistakes.

References

1
Gittings
R
John Keats
 , 
1968
London
Heinneman
2
Walker
C
Walking north with Keats
 , 
1992
New Haven, CT
Yale University Press
3
Lowell
A
John Keats
 , 
1925
London
Jonathan Cape
4
Lord
Brock
John Keats and Joseph Severn: the tragedy of the last illness. Keats-Shelley Memorial Association Sydenham Lecture
 , 
1973
5
Sharp
W
Life and letters of Joseph Severn
 , 
1892
London
Low, Marston, and Co.

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