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“but being deaf, the Spirit not the Body tires” – the Duke of Wellington’s Hearing Loss

Hugh Dominic WStiles3 May 2019

Arthur Wellesley, the Duke of Wellington, who was born 250 years ago, in 1769, suffered from noise-related hearing loss caused by artillery.  William Wright tells us,

The Duke of Wellington was inspecting an experimental carriage for a howitzers and whilst in advance of the gun, gave the word ” Fire ;” the result was the rupture of the membrane of the drum of the left ear. The Duke went immediately to Mr. Stevenson who told his Grace the story, about thickening the drum of the ear. The solution of caustic was applied; instant pain ensued, from the caustic passing through the ruptured membrane amongst the ossicula, and very sensitive internal tissues. Within six hours the Duke was conveyed home from Lord Liverpool’s, in a state of insensibility, and it was only by most careful, skilful treatment that his life was then preserved. He went to Verona, a great sufferer, and the country had very properly to make a handsome compensation to Dr. Hume, and his family, for giving up his practice to attend the Duke on his mission. (Wright, 1860, p.75-6)

Graham Smelt says that this was on On August the 5th, 1822.  His hearing loss was made considerably worse by the botched treatment, a story related by a Mr Gleig, in an anecdote that suggests it was Hume who was to blame –

The Duke, many years ago, being deaf, sent for his medical man, who poured some stuff into his ear, not knowing that the drum of the ear was broken. This proved very mischievous in its results. The Duke said it was not sound that was restored to him; it was something terrifically beyond sound: the noise of a carriage passing under his window was like the rolling of thunder. Thus suffering, he returned home about the middle of the day, and went to bed. Next day, Dr. Hume called and found the Duke staggering about the room. Dr. Hume, although he well knew the Duke’s temperate habits, supposed that he had taken a little too much wine overnight, and had not recovered from it. He was leaving the room, when the Duke said to him : Hume, I wish you would look to my ear ; there is something wrong there.’ Hume looked and saw that a furious inflammation had begun, extending to the brain ; another hour, and the stuff would have done for the Duke what all his enemies had failed to do : it would have killed him. Hume bled him copiously, sent for Sir Henry Halford and Sir Astley Cooper, who treated him with great skill, and brought him round. The poor man came next day and expressed his great regret. The Duke spoke to him in his kindest manner and said, I know you did not mean to harm me ; you did your best, but I am very deaf.’ Upon which, the Doctor said, I am very sorry for it ; but my whole professional prospects are at stake, and if the world hears of it I shall be ruined.’ ‘The world need not hear at all about it,’ said the Duke; ‘keep your counsel, and I’ll keep mine.’ The Doctor, encouraged by this, went a little further : Will you let me attend you still, and let the world suppose that you still have confidence in me ?’ ‘No, no,’ said the Duke, ‘I cannot do that ; that would not be truthful.’ (Davies, 1854 p.16-17)

To me this sounds like a well-rehearsed anecdote, but there is something ‘missing,’ it seems to me, in Wright’s account, in that he seems to imply that Hume had some hand in the affair without explicitly saying so.  Or is he just omitting Stevenson’s name, and ‘the poor man’ is Stevenson?  Smelt says that Stevenson was to blame, and that Hume treated him afterwards.  In an earlier book, Wright tells us –

Deleau states that he can reach the cavity of the tympanum by a bent probe, or catheter. If he even can do so, which I consider is very problematical, I am convinced the operation is attended with considerable danger, for the ossicula (the small bones) which extend from the inside of the membrana tympani, to the opposite side of the cavity, would be in great danger of being forced from the situation in which Providence has been pleased to place them, or their functions would be otherwise diminished, or destroyed, and such would be the effect of any injury being inflicted on this delicate organization, that inflammation of the brain, and even death, would be a probable consequence. An example of this was unfortunately nearly afforded about the end of 1822, or beginning of 1823, in the case of the Duke of Wellington, a lotion of lunar caustic had been dropped into the external auditory passage, there was an opening at the time through the membrane (or drum), from an accidental cause, and the caustic lotion entered the cavity beneath, containing the highly sensative [sic] integuments, and machinery therein placed ; the results were intense pain; in a few hours inflammation of the brain, with symptomatic fever, and his life was only preserved by the most prompt and efficient treatment pursued by his Physician, aided by other medical and surgical advice derived from the first men of the age. In June, 1823, I was called into attendance on his Grace, as his aurist, and continue still to attend him when necessary ; even at this distant period from the unfortunate occurrence, the Duke feels sufficient unpleasant effects occasionally, not to allow him to forget it, independent of the privation of his left ear.* Similar, if not even worse, must necessarily be the consequence of introducing an instrument into the cavity of the tympanum, even if the patient be in a state of health; but if there exist any tendency to inflammatory action, scrofula, or erysipelas, the danger is increased, and the disastrous effects, or even fatal termination of the experiment, for it is nothing more in ninety-nine cases out of a hundred, unavoidable. (Wright, 1839, p.55-7)

* In pp. 159 and 160, of “An Exposition of Quackery and Imposture in Medicine,” written by Dr. Caleb Ticknor, of New York, republished in this country, which I edited, and upon which I wrote copious notes, will be found a further account of the Duke of Wellington’s case.

Note how free doctors were then with patient information, while the patient was still alive. Smelt suggests as well as the seriously damaged ear, he also had noise-induced hearing loss in his other ear as he got older.

In 1852 the Duke wrote in a letter,

I have none of the infirmities of old age I excepting Vanity perhaps. But that is a disease of the mind, not of the Body ! My deafness is accidental ! If I was not deaf, I really believe that there is not a youth in London who could enjoy the world more than myself or could bear fatigue better, but being deaf, the spirit, not the body, tires. One gets bored, in boring others, and one becomes too happy to get home. (Wellington, 1854, p.314-5)

Losing his hearing had other consequences, as we see from this on February 20th, 1848 from the Greville memoirs –

At the House of Lords on Friday night, for the Committee on the Diplomatic Bill. Government beaten by three, and all by bad management ; several who ought to have been there, and might easily have been brought up, were absent : the Duke of Bedford, Duke of Devonshire, Lord Petre, a Catholic, dawdling at Brighton, and Beauvale. The Duke of Wellington, with his deafness, got into a complete confusion, and at the last moment voted against Government. (Greville, 1888, p.129)

When he was in his eighties, as members of Derby’s 1852 government were announced, the now quite deaf Duke kept repeating, “Who? Who?”  It became known as the “Who? Who?” ministry.

Davies, George Jennings, The completeness of the late duke of Wellington as a national character, 1854

Greville, Charles Cavendish Fulke, The Greville Memoirs: A Journal of the Reigns of King George IV, King … 1888

Hazlitt, William, ed, Arthur Wellesley Duke of Wellington, The Speeches of the Duke of Wellington in Parliament, Volume 2, 1854

Smelt, Graham, Wellington’s Deafness. Abstract presented at the meeting British Society for the History of ENT, Held December 1st 2011 In the Toynbee McKenzie Room, at the Royal Society of Medicine, London

Wright, William, A few minutes’ advice to deaf persons…, 1839

Wright, William, On the varieties of deafness and diseases of the ear, 1829

Wright, William,  Deafness and Diseases of the Ear: The Fallacies of Present Treatment Exposed … 18

How Do Storms Affect Asthma?

Hugh Dominic WStiles18 June 2018

by Abir Mukherjee

D’Amato and colleagues discuss the idea that thunderstorms in pollen season can induce severe asthma attacks in susceptible pollinosis patients.
The scientific background to this observation is that that storms can concentrate pollen grains at ground level, which may then release allergenic particles of respirable size in the atmosphere after their imbibition of water and rupture by osmotic shock. During the first 20-30 minutes of a thunderstorm, a large amount of pollen is dispersed into the atmosphere as a bioaerosol of allergenic particles, which can induce asthmatic reactions, often severe. Subjects without asthma symptoms, but affected by seasonal rhinitis can also experience an asthma attack
A key message for susceptible patients is increasing awareness of being outdoors during a thunderstorm in the pollen season could trigger an asthma attack.
Davies et al in the BMJ (2018) also discuss the phenomenon of epidemic thunderstorm asthma. They suggest proactive measures to identify and pre-emptively protect susceptible people are critical to mitigating the effects of thunderstorm asthma. Whilst known previous asthma seems to be an inadequate predictor of risk, seasonal allergic rhinitis (hay fever) from grass pollen allergy, and degree of sensitisation, appears to be a universal risk factor among affected patients.

References

How Do Storms Affect Asthma?
Author(s) D’Amato G; Annesi-Maesano I; Vaghi A; Cecchi L; D’Amato M
Source Current Allergy and Asthma Reports; Mar 2018; vol. 18 (no. 4); p. 24

Thunderstorm asthma: controlling (deadly) grass pollen allergy
Author(s) Davies, J.M., Thien, F. and Hew, M., 2018.
Source BMJ: British Medical Journal (Online), 360.5

Asthma Patient Information

Hugh Dominic WStiles1 May 2018

A post from our Clinical Librarian, Abir Mukherjee @ClinicalLibUCLH 

Some basic patient information on asthma as a condition and management can be found at the following sites:

  • Patient Info provides a printable overview of asthma as well as how to manage it and what things may act as triggers. https://patient.info/health/asthma-leaflet
  • NHS Choices also discusses causes, triggers and complications in simple language. https://www.nhs.uk/conditions/asthma/
  • The British Lung Foundation provides a range of information on causes, symptoms , management and has a specific section for asthma in children. https://www.blf.org.uk/support-for-you/asthma
  • The AAIR Charity (Asthma, Allergy & Inflammation Research) focusses on effective treatments and cures for allergic diseases, notable research has included the identification of an asthma gene. It has some basic background information for patients on its website. http://www.aaircharity.org/

Asthma – 5 articles on treatment from 2018

Hugh Dominic WStiles1 May 2018

A post from our Clinical Librarian, Abir Mukherjee  @ClinicalLibUCLH

Here are five recent articles on asthma treatment from 2018:

  • Akhbari, M., Kneale, D., Harris, K.M. and Pike, K.C., 2018. G460 (P) Interventions for autumn exacerbations of asthma in children: a systematic review. Cochrane Reviews
  • Chang, Y.S., 2018. Non-pharmacologic Therapies for Severe Asthma. In Severe Asthma (pp. 123-129). Springer, Singapore.
  • Larsson, K., Ställberg, B., Lisspers, K., Telg, G., Johansson, G., Thuresson, M. and Janson, C., 2018. Prevalence and management of severe asthma in primary care: an observational cohort study in Sweden (PACEHR). Respiratory research, 19(1), p.12.
  • Licari, A., Castagnoli, R., Brambilla, I., Marseglia, A., Tosca, M.A., Marseglia, G.L. and Ciprandi, G., 2018. New approaches for identifying and testing potential new anti-asthma agents. Expert opinion on drug discovery, 13(1), pp.51-63.
  • Sobieraj, D.M., Weeda, E.R., Nguyen, E., Coleman, C.I., White, C.M., Lazarus, S.C., Blake, K.V., Lang, J.E. and Baker, W.L., 2018. Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma: A Systematic Review and Meta-analysis. JAMA, 319(14), pp.1485-1496.

Chang (2018) identifies inhaler technique and adherence as the the key factors of successful management in severe asthma. He discusses factors to aid self-management such as patient education to maintain regular medications; a written action plan and awareness of environmental triggers such as inhalant allergens, smoking, air pollution, respiratory infections, and obesity.

Licari et al (2018) in their review provide a comprehensive and updated overview of the currently available, new and developing approaches for identifying and testing potential treatment options for asthma management. They discuss future therapeutic strategies for asthma needing the identification of reliable biomarkers that can help with diagnosis and endotyping, in order to determine the most effective drug for the right patient phenotype. Furthermore they conclude that a better understanding of the mechanisms of airway remodeling will likely optimize asthma targeted treatment.

Pike et al (2018) in their Cochrane systematic review found that seasonal omalizumab treatment from four to six weeks before school return may reduce autumn asthma exacerbations. Negative associations included injection site pain and treatment costs.

Sobierj and colleagues (2018) in a systematic review and meta-analysis discuss combined use of inhaled corticosteroids and long-acting beta-agonists (LABAs) as the controller and the quick relief therapy termed single maintenance and reliever therapy (SMART) which could be a potential therapeutic regimen for the management of persistent asthma.

A Swedish study by Larsson found that patients with severe asthma had few regular contacts with both primary and specialist care, and more than half of them experienced poor asthma control.

Please contact Hearing Library staff if you have any trouble accessing or finding these articles (or others!).

Hearing Awareness Day – Patient Information

Hugh Dominic WStiles27 February 2018

By Abir Mukherjee @ClinicalLibUCLH

This second post of this series highlights a small selection of reliable patient information resources for hearing loss in general. Once again, these sources either meet the NHS Information Standard or are produced by reputable organisations.

Action on Hearing Loss (formerly the Royal National Institute for Deaf People – RNID) estimates that one in six people in the UK has hearing loss or is deaf, and increasingly people are accessing help to hear better. Their website discusses in clear terms, the different types and causes of hearing loss and deafness, as well as what people can do if they are worried about hearing loss – from seeing a GP to getting hearing aids or a cochlear implant. They also have a very useful glossary for hearing disorders and symptoms. NHS CHOICES also provides a relevant overview of hearing loss including symptoms and treatment options. In line with this year’s World Hearing Day theme of ‘Hear the Future’ they also discuss some simple but common sense ways of reducing the risk of damage to hearing such as:

· not having the television, radio or music on too loud

· using headphones that block out more outside noise, instead of turning up the volume

· wearing ear protection (such as ear defenders) in a noisy environments

· using ear protection at loud concerts and other events where there are high noise levels

· not inserting objects ears – this includes fingers, cotton buds, cotton wool and tissues

· Get a hearing test as soon as possible if worried about hearing loss -the earlier hearing loss is picked up, the earlier something can be done about it.

ENT UK, produced by the Royal College of Surgeons also has easy to understand information on ear anatomy and how the ear works to explain hearing disorders and common causes. Patient Info also has a range of pertinent information on hearing disorders and downloadable leaflets.

Background for World Hearing Day

Hugh Dominic WStiles26 February 2018

By Abir Mukherjee

World Hearing Day is held on 3 March each year in order to raise awareness and understanding of deafness and hearing loss, and to promote ear health and the care provided by audiologists across the world.

This year’s theme is “Hear the future”, and World Hearing Day 2018 hopes to draw attention to the anticipated rise in people with hearing loss around the world in the coming decades.

The WHO’s figures estimate 466 million people worldwide live with disabling hearing loss. Unless action is taken, by 2030 the number will rise to nearly 630 million.

Key initiatives for #WorldHearingDay2018 include preventative strategies to stem the rise in hearing loss and steps to ensure access to the necessary rehabilitation services; communication tools and products for people with hearing loss.

All of these are important areas of research for Action on Hearing Loss, the UCL Ear Institute, the Royal National Throat, Nose and Ear Hospital, and many other colleagues and organisations in the UK and further afield.

Throughout the week we will be writing blogs highlighting evidence and information in support of “Hear the future”, and World Hearing Day.

References: World Health Organization. (2018). 3 March 2018: World Hearing Day. [online] Available at: http://www.who.int/deafness/world-hearing-day/whd-2018/en/ [Accessed 23 Feb. 2018].

Tinnitus in the media…

Hugh Dominic WStiles9 February 2018

Tinnitus frequently appears in newspapers and online news sources. Because anyone who suffers from a chronic condition can get frustrated, despressed and angry at the inabilty of medical science to cure the condition, that makes people ready to grasp at anything that could give them hope, offering to alleviate or cure the condition. Tinnitus is no exception, and below are a few recent stories that cover it, all in this case from the Daily Mail, though other papers and websites could equally have been included.

It pays to be a little sceptical with health stories.  Always ask yourself the questions –

  • who produced the study or studies behind the story?
  • are they reputable researchers, or are they selling something?
  • has the article given the original source where the study is published?
  • is the newspaper story written by someone who knows what they are writing about, or is it a staff writer who is regurgitating a press release which has a positive spin?
  • If the study is based on a group of patients, was it a small number or a large number?

I am not saying these stories are invalid, but the headlines are never written by the author, and they often disguise the facts.  People come away remembering the headlines, not the complete story.  Read these stories, but with caution.

Do YOU suffer from tinnitus? Study reveals ‘resetting’ brain cells using electric currents can alleviate the misery of phantom sounds
Read more: http://www.dailymail.co.uk/health/article-5232433/Study-reveals-resetting-brain-cells-cure-tinnitus.html#ixzz56cL3gYau

Google alert helps to end a former Royal Marine’s 10-year tinnitus hell: Notification highlighted pioneering IPOD-based therapy that has allowed veteran to ‘function again as a human being’
Read more: http://www.dailymail.co.uk/health/article-5030949/Royal-Marine-tinnitus-finds-relief-IPOD-therapy.html#ixzz56cMfslW7

Fed up with the noise of modern life? FEMAIL reveals how at home EAR YOGA can help
Read more: http://www.dailymail.co.uk/femail/article-5337717/Fed-noise-modern-life.html#ixzz56cV58VzY

Tinnitus Awareness Week 2018 – Suggested reading

Hugh Dominic WStiles8 February 2018

Tinnitus is an active area for research, because it bothers so many people.  Even if you do not have it, there is a good chance you know someone who has it in some form, ranging from a minor irritation to a serious frustration.  People are looking for cures, but management of the condition seems the most realistic solution for most people.  Here are a few suggested books that might help those who have tinnitus.

For non-experts –

Living with tinnitus and hyperacusis, by Laurence Mckenna, David Baguley and Don McFerran, 2010.

This book has 4 or 5 stars in 75% of the Amazon.co.uk public reviews.

Tinnitus: Questions and Answers, by Jack Vernon and Barbara Sanders, 2001. ISBN-13 978-0205326853

“The questions in this book are from patients. The answers are written for patients and for interested health care providers too. The book covers causes, treatments, and other topics with a format similar to the column written by the author in “Tinnitus Today” magazine.”

For Experts –

Tinnitus Retraining Therapy: Implementing the Neurophysiological Model, by Pawel Jastreboff and Jonathan Hazell, 2004.  ISBN 0521592569

‘One of the nice things about being asked to review a book is that you get to keep a copy if it – and this is certainly a book well worth keeping. This is a thought-provoking and stimulating book for dipping into, for referring to, for speed-reading and for reading thoroughly from cover to cover. It will be a useful addition to the shelves of professionals who work with people with tinnitus.’ Tinnitus Focus

Tinnitus, by by David Baguley, Gerhard Andersson,‎ Don McFerran,‎ Laurence McKenna, 2nd edition 2013. ISBN-13: 978-1405199896

‘The 2nd edition has been thoroughly updated and revised in line with the very latest developments in the field. The book contains 40% new material including two brand new chapters on neurophysiological models of tinnitus and emerging treatments.’

Tinnitus Awareness Week – Patient Information

Hugh Dominic WStiles8 February 2018

By Abir Mukherjee @ClinicalLibUCLH

Tinnitus Week is an international event raising global awareness of this condition taking place from 5-11 February 2018. The aim of the week is to raise awareness of the condition. This blog post gives a quick overview of some patient information sources, all of which meet NHS England’s patient information standard.

The Action on Hearing Loss website has a number of free factsheets on its website in addition to a tinnitus helpline number: https://www.actiononhearingloss.org.uk/hearing-health/tinnitus/

The British Tinnitus Association believes the condition affects approximately 1 in 10 of the population in the UK. Other details about tinnitus awareness week, information sheets, and a helpline can be accessed at their website: https://www.tinnitus.org.uk/h-blog

The website also has a case study of living with tinnitus which is now on BBC news.

NHS Choices defines tinnitus as ‘hearing sounds that come from inside your body, rather than from an outside source’ with sufferers describing ‘ringing in the ears’ or ‘buzzing; humming; grinding; hissing or whistling.’ As a starting point for most patient information it can be accessed at: https://www.nhs.uk/conditions/tinnitus/

An overview of symptoms and treatment options is also available from the Patient.co.uk website at: https://patient.info/health/tinnitus-leaflet

ENT UK, a professional membership body that represents Ear, Nose and Throat and its related specialities also has patient information on tinnitus that can be downloaded from: https://www.entuk.org/sites/default/files/files/ENT/About%20Tinnitus%206pp%20DL%20%2809028%29_7_16.pdf.

“The patient bore the operation with great fortitude” – Lochland Shiel’s facial exostosis

Hugh Dominic WStiles28 April 2017

In Guy’s Hospital Reports for September 1836, there is an article, “Cases of exostosis of the bones of the face, disease of the cranium, and fractures of the frontal and parietal bones requiring operation, by Mr. Morgan.”   Mr. John Morgan was a pupil of Sir Astley Cooper.  Plarr’s lives of the Fellows, tells us that Morgan “showed an intense interest in natural history, and began to stuff birds and small animals almost as soon as he could use a knife and his fingers.”   We also discover there, that he dissected an elephant named ‘Chum,’ took an awful lot of snuff, and was one of the founders of the Zoological Gardens in Regent’s Park, now London Zoo.  His brother-in-law William Gosse who was a surgeon and was related to Philip Henry Gosse, emigrated to Australia.

The case we are looking at, Case 1. Exostosis of the Bones of the of the Face, (the notes taken by Mr. Collin), covers an unfortunate Irish labourer, Lochland Shiel, admitted on the 1st of August, 1835 (Guy’s Hospital Reports, p.403-6).  At the time he was 24 years of age.  Shiel told the doctors that until he was fifteen he had good health, when he noted a small tumor in his right nostril.  He was told by ‘a medical man’ that it was ‘of no consequence.’  However, as we can see in the plate, after nine years it had grown greatly, distorting his face,

the right nostril being enormously expanded and closed by the enlargement of the tumor, which, from its size, completely concealed the eye on that side, and extended downwards into the mouth, being there connected with the palatine and alveolar processes of the right superior maxillary bone; projecting also forwards, so as to press the lip beyond the teeth, to the extent of two inches.  The bones apparently implicated in the disease were the ossa nasi, superior maxillary bone, vomer, and the inferior turbinated and malar bones.
[…]
The poor fellow, when admitted, complained of no pain; and I could not find that his sufferings had given him much inconvenience, during the whole of his disease.The general health appeared good; but he was greatly emaciated, more, I believe, from want of proper food, than from the constitutional effects of his disorder.

Deciding that the tumor was common exostosis, an opinion in which Morgan was supported by Sir Astley Cooper and Dr. Hodgkin, he “removed the morbid excrescence” on the 6th of November.  He first made an incision over the right nostril, to ascertain that it was indeed exostosis.

A semilunar incision was then made, extending over the nostril, from the internal angle of the right eye to the centre of the the upper lip.  A similar incision was made on the outer side, commencing at the angle of the eye, and joining with the other, at the lip.  The integuments were then dissected from around the tumor, , and a metacarpal saw was used for its removal; and as it was of a spongy texture, it offered little resistance to the instrument.  No great quantity of blood was lost during the operation , the exostosis not being very vascular; and it was only found necessary to secure one  vessel, a superficial branch of the transverse facial.  all further disposition to haemorrhage was easily restrained by pressure.

After the tumor had been thus removed, the integuments were brought together by an uninterrupted suture; a dossil of lint was placed over the wound, and confined by adhesive plaster; and over all, a light bread-and-water poultice was applied.

The patient bore the operation with great fortitude; and said afterwards, that he suffered but little pain, excepting when the first incision was made.
[…]
Up to the the present time, the patient has been going on well; all discharge from the face has almost entirely ceased: hardly any exfoliation  of bone has taken place; his general health is restored.  The present appearance of his face is correctly represented in the accompanying plate.  (Guy’s Hospital Reports, 1836)

Shiel

Unfortunately I cannot locate any record of Lochland Shiel on family history records or census returns, though a Locklin Sheels married a Margaret Boyle in Newcastle-under-Lyme on the 22nd of December, 1834.  That might be him.  It could be that he was missed, it could be he spent time in Ireland, or it could be that his name has been wrongly transcribed. If you have any ideas about where in Ireland he was from, or any family, do contribute in the comments.  In the spring of 1842 Shiel died in Birmingham.

We have been unable to learn the particulars of the termination of the case. It may, however, be observed, that his death did not take place til nearly seven years after the operation; so it may fairly be said to have been prolonged by it for nearly that period. It is, however, impossible to look at the cast taken after death without marvelling that life could have been prolonged to such a period. The growth appears to have been simply enormous — larger indeed than the head itself. (Guy’s Hospital Reports, 1842)

I have been unable to find a death record for anyone of his name. Someone must have dissected his remains to make a cast of the tumor – and presumably, his skull. Below is the cast that shows the tumor.  As you can see, it had grown enormously in the following years.  The dotted line points to the tiny space through which Shiel ingested food.

Skull ShielGuy’s Hospital Reports, No 2, September 1836 p. 403-6

Guy’s Hospital Reports, No 15, October 1842 p. 491

A System of surgery v. 3, 1882, p.259

[minor updates 15/10.2018]