From Nelson Hospital, Nelson, New Zealand (Dr Wilson); and MedicalCollege of Ohio, Toledo (Dr Ravin).
The poor health of Samuel Johnson (1709-1784) has fascinated the publicfor more than 200 years. The illnesses of few famous men, with the possibleexception of Napoleon, have attracted more speculation. Johnson was an outstanding18th-century literary figure, an essayist, novelist, and poet, and is particularlyfamous as the creator of the first important dictionary of the English language.His writings and those of his physicians and friends, particularly his biographer,James Boswell, provide an intimate account of a cultural icon.
Samuel Johnson had a multitude of physical and psychological ailments.From the beginning of his life as a hypoxic newborn, he was troubled by numerousillnesses, including neonatal abscess of the buttocks, probable smallpox,and deafness in the left ear (and both ears later in life). As he put it,"My health has been, from my twentieth year, such as has seldom afforded mea single day of ease."1(pp147,148) Themost important of his ailments were scrofula (primary tuberculosis of thecervical lymph nodes, known during his lifetime as "the King's evil"); depression("I inherited a vile melancholy from my father")2(p215); possibly Gilles de la Tourette syndrome, since he experiencedinvoluntary contortions, gesticulations, and oral outbursts3;asthma; and dropsy (edema). In adulthood, he also experienced insomnia, adeath phobia, intermittent excesses of alcohol and opiates, obesity, dyspepsia,flatulence, heart failure, gout, and stroke. It is hardly surprising thatJohnson was led to comment, "Human life is everywhere a state in which muchis to be endured, and little to be enjoyed."4(p50)
A brief summary of Johnson's life is a daunting task, because he wasa man of many remarkable accomplishments. He was born in the town of Lichfieldin 1709, the son of a bookseller. He studied languages, literature, ethics,and theology at the University of Oxford, but, impoverished and depressed,he left before obtaining a degree. Nervousness, odd manners, and ill healthmade it difficult for Johnson to find work. Eventually, he became a schoolmasterand later was employed by a publisher. At the age of 26 years, he marrieda widow 20 years older than he. Later he would write, "Marriage has many pains,but celibacy has no pleasures."4(p99) After a boarding school he established failed, Johnson moved to Londonin 1737 to begin his writing career. Once established, he wrote for Gentleman's Magazine and published a series of articlesabout important physicians in history, including Boerhaave and Sydenham. Hecollaborated with Robert James, MD, in creating the MedicinalDictionary (1743-1745), a 1000-page compendium of pharmacology writtenfor a general audience.
Public recognition of Johnson's work came with the first edition ofhis Dictionary of the English Language (1755), whichhe compiled almost single-handedly and is a landmark of literary achievement.It defines more than 40 000 words, was the first important and preciseEnglish dictionary, and went through 5 editions during his lifetime. In honorof this accomplishment, he was granted a royal pension, even if he had definedthe word pension sarcastically in his dictionaryas "pay given to a state hireling for treason to his country."5
After Trinity College, Dublin, gave him an honorary doctoral degreein 1764 and the University of Oxford gave him another in 1775, he became knownas Dr Johnson. He had risen from a humble background to become the preeminentliterary figure of his era. He knew most of England's great thinkers, andhis "supreme enjoyment was the exercise of reason."6(p66) Johnson was more famous for his brilliant conversational remarksthan for his writings (see Box).Although he was eccentric in some ways and unusual in appearance (Figure 1 and Figure 2), his peculiarities were overlooked as soon as he beganto speak. He mixed serious comments with a good sense of humor.7(p269) Criticism did not faze him. He considered it better to be criticizedthan overlooked and degrading to respond to insults. box
"I believe every man has found in physicians great liberality and dignityof sentiment, very prompt effusion of beneficence, and willingness to exerta lucrative art where there is no hope of lucre.7(p223)
"That the greatest physician of the age [Sydenham] arrived atso high a degree of skill without any assistance from his predecessors, andthat a man eminent for integrity practiced medicine by chance and grew wiseonly by murder, is not to be considered without astonishment."8
"A suffusion of the eye, when little clouds, motes, and flies, seemto float about in the air; when confirmed, the pupil of the eye is eitherwholly, or in part, covered, and shut up with a little thin skin, so thatthe light has no admittance."5 (quoting Quincy)
"To depress the film that overspreads the pupil of the eye. Some artist,whose nice hand couches the cataracts, and clears his eyes, and all at oncea flood of glorious light comes rushing on his eyes."5 (quotingDennis)
"A fault in the eye, which changes the crystalline humor into a greyishcolour, without detriment of sight, and therein differs from what is commonlyunderstood by suffusion."5 (quoting Quincy)
"Perception by the eye, the sense of seeing. O loss of sight, of theeI most complain! Blind among enemies, O worse than chains, Dungeon or beggary,decrepit age!" 5 (quoting Milton)
Sir Joshua Reynolds, English. Samuel Johnson, circa 1790. Oil painting. Reprinted bykind permission of Loren and Frances Rothschild.
After Joshua Reynolds, English. Samuel Johnson, late 18th or early 19th century. Pastel.Reprinted by kind permission of the trustees of Dr Johnson's Birthplace.
Dr Samuel Johnson had no medical degree, but because of his friendshipwith physicians, study of medical literature, and understanding of human behavior,people would occasionally ask if he were a physician or even an oculist.2(p96) James Boswell considered him a "greatdabbler" in medicine.9(p152) Henoted that Johnson took "a peculiar pleasure in the company of physicians,"some of whom were the leading practitioners of his day.1(p293) If one of his friends would complain about physician's fees,he would challenge them to produce a single example of a large estate foundedon a medical practice.7(p223) Incontrast to his friendly attitude toward physicians, "Johnson never had agood word for an attorney."7(p151) Johnsoneven associated attorneys with street robbers and wrote this couplet: "Thereambush here relentless ruffians lay, And here the fell attorney prowls forprey."10(p126)
Johnson defined the word patron humorouslyin his dictionary as "a wretch who supports with insolence, and is paid withflattery."5 A decade after the dictionary cameout, he came under the patronage of Henry Thrale, a wealthy brewer, and hisliterary wife, Hester, who wrote a biography of Johnson. But it was JamesBoswell, a young Scottish lawyer, who made his own fame with his Life of Samuel Johnson (1791). Undoubtedly, this is the best knownand most widely read biography ever written. Johnson died a national celebrityand is buried in Westminster Abbey.
"My mother had a very difficult and dangerous labour . . . I was bornalmost dead, and could not cry for some time."11(p3) He was placed with a wet nurse and 10 weeks later "taken home apoor, diseased infant, almost blind."11(p5) Many commentators have felt the wet nurse gave Johnson scrofula,which affected his eyes, but this hypothesis is unlikely to be correct, becausescrofula is not transmitted through breastfeeding, and tuberculosis in infancyis nearly always fatal.12 Johnson's first ocularproblem may have been ophthalmia neonatorum.13
Johnson developed scrofula at approximately age 2 years from infectedcow's milk, and this caused many problems during his childhood. His eyes wereseverely affected. Treatment included making an "issue" in his left arm, anincision that was kept open with a small foreign body such as a pea. Thisobsolete form of therapy was intended to drain away evil humors. He was takenthe then–long distance of 20 miles to consult an oculist, Dr ThomasAttwood, but no records of his diagnosis or treatment have survived. At age2½ years, his mother took him to London to be 1 of 200 individualsgiven the "royal touch," an ancient magical ceremony designed to treat scrofula.He was examined by the court physician, blessed by the court chaplains, andpresented with a golden amulet by Queen Anne.11(p8) He wore this charm around his neck ever after. Not surprisingly,Johnson's scrofulous sores were not cured, and the scars on his face and neckwere visible for the rest of his life.
Because of his poor eyesight, Johnson did not go to school until hewas 8 years old. Although the school was fewer than 150 yards from his home,a servant would escort him there and back or even carry him. Boswell describeshow once, when the servant was late, Johnson started off alone and was obligedto kneel down to see the gutter before he ventured to step over it.6(p39) His mother was afraid he would fallinto the drain in the street or even the sewer at the market. He often usedhis limited eyesight as a convenient excuse to avoid attending church andwould wander off into the countryside instead, taking along something to read.Poor vision did not prevent him from doing well academically at school, butit kept him from playing the usual childhood sports.
There is little new mentioned about his eyes until 1756, when 47-year-oldJohnson wrote, "The inflammation is come again into my [right] eye, so thatI can write very little."14(pp132,133) He was relieved when improvement followed and thanked "Almighty God,who hast restored light to my eye, and enabled me to pursue again the studieswhich thou hast set before me."11(p60) Unfortunately, the problem recurred later that year, and he attributedit to the scrofula he had acquired in childhood. Boswell first met Johnsonin 1763, when the latter was 54 years old, and found his appearance dreadfuldue to inflamed eyes, ungainliness, strange movements, and scars from scrofula.
Eye pain occurred during the next few years, and in letters writtenin 1773 Johnson wrote,
"My fever has departed but has left me a very severe inflammationin the seeing [right] eye. . . . My eye is yet so dark that I could not read.. . . I read for a very short time, in a book of a minute print, and at nightfelt a pain in my eye, which was next day inflamed to a very great degree.15(pp35,37,40)
He was treated by bleeding and purging. A few months later he recorded,"My eye is almost recovered, but is yet a little dim, and does not like asmall print by candlelight."15(p45) Theattack was discussed with a physician, John Mudges, who said, "unless Mr Johnsontook the greatest care to have the inflammation removed the danger of losinghis sight was very great."10(p506) Therecovery was not complete, but Johnson felt well enough to embark on a tourof Scotland with Boswell a few weeks later.
Johnson's left eye was the weaker of the two, and he once said, "thedog was never good for much."6(p41) Boswellconcurred, writing that scrofula "hurt his visual nerves so much, that hedid not see at all with one of his eyes, though its appearance was littledifferent from that of the other."6(p41) Boswell acknowledged that many of Johnson's friends knew he had anocular defect,
"though I never perceived it; I supposed him to be only near-sighted;and indeed I must observe, that in no other respect could I discern any defectin his vision; on the contrary, the force of his attention and perceptivequickness made him see and distinguish all manner of objects.6(p41)
Johnson once used his myopia as a convenient excuse to not go on anexpedition, saying
"I see but at a small distance. So it was not worth my whileto go to see birds fly, which I should not have seen fly; and fishes swim,which I should not have seen swim.10(p148)
Traditional teaching is that Johnson's left eye was either blind oramblyopic from scrofula and the right eye had a lesser degree of damage. Hismyopia is well documented. On the other hand, some of his contemporaries'accounts give contradictory evidence and indicate his vision was reasonablygood. Fanny Burney, who described his nearsightedness, also said, "he seeswonderfully at times."1(p160) Hewas able to tell the time on the Lichfield town clock and could make out detailsinside a French cathedral. Surprisingly, there is no mention of his eyes duringthe 9 years he labored on his dictionary. Sir Joshua Reynolds noted his intermediatevision was subnormal, saying "pictures he could not well see."16 Johnsonappeared to enjoy art for he left behind a collection of 146 portraits whenhe died.7(p214) It is difficultto believe that at the age of 66 years, Johnson would have gone on a 100-dayfrolic around Scotland with Boswell if his visual impairment were severe.
Johnson read with the material held very close to his face (Figure 1). His friend Thrale noted that Johnson'swigs were scorched from reading too close to a candle and was seriously afraidthat Johnson might burn himself up while reading in bed.7(p307) According to the sister of the artist Sir Joshua Reynolds, Johnson'ssight was so poor that he could not distinguish faces half a yard away.10(p92) Hester Thrale believed his crudeeating habits owed something to his poor eyesight. Johnson confirmed as muchto Boswell, saying "I am short-sighted, and afraid of bones, for which reasonI am not fond of eating many kinds of fish, because I must use my fingers."1(p206)
Although willing to acknowledge that he was myopic, Johnson was defensiveabout the appearance of his eyes. After seeing a portrait of himself paintedby Sir Joshua Reynolds that depicted him holding a book very close to hisface (Figure 1), he protested thathe "would not be known by posterity for his defects only . . . I will notbe blinking Sam."9(p273) Johnsondefines blinkard in the fourth edition of his dictionaryas "one that has bad eyes" and to him to blink meant"to see obscurely." (Modern dictionaries define blinkard as an archaic word meaning one who blinks with, or as if with, weakeyes.)
There has long been uncertainty concerning the relative contributionof eye disease and refractive error to Johnson's visual impairment. Accordingto an account published in 1784, Johnson did not wear glasses "because hewas assured they would be of no service to him."7(p343) He was well aware of the benefits of glasses. His friend Reynoldswore them, and Johnson was constantly mingling with physicians who would haveadvised him to try them. He states in his dictionary, "It is no fault in thespectacles that the blind man sees not."5 Johnsoneven discussed the action of lenses with King George III. Concave lenses forthe correction of myopia were available in Johnson's day, but cylinders werenot, and we assume he experimented with glasses but did not find them helpful.
There are many paintings, etchings, pastels, and sculptures of Johnson,but it is difficult to use these to diagnose his ocular problems. Evidencefrom portraiture is apt to be unreliable, because artists often flatter theirsitters to please them. Johnson may have had a congenital left superior obliquepalsy, because a head tilt to the right shoulder is observable in severalportraits of him (Figure 2).
The ocular inflammation Johnson experienced as a child, which may havebeen phlyctenular keratoconjunctivitis, could have resulted in fine scarringof the cornea and astigmatism and reduced his visual acuity. No scarring ofthe ocular surface or strabismus is evident in his portraits. The defectswere not severe enough to result in loss of binocularity, because he maintaineda head tilt. The inflammation he encountered as an adult was probably a keratoconjunctivitis,which was not severe, because he maintained adequate functional vision forthe rest of his life. His visual impairment, which seems to have been severein childhood, appeared to be less of a problem when he was an adult, possiblyas a result of slow clearing of phlyctenular disease and adaptation to hisrefractive error. He could read and write to the end of his life, and hispenmanship was legible a week before he died. A postmortem examination wasmade 2 days after his death, which found emphysema, aortic sclerosis, gallstone,small kidney, hydrocele, and varicocele, but the head and eyes were not evaluated.
Although there is much we can be sure of, a definitive ocular diagnosisis elusive. Much remains speculative, including the impact of his eye diseaseon his life and its severity. It is likely that his poor distance vision ledhim to concentrate on near work and influenced his career choices toward booksand literature.
His household included a strange collection of humanity. One residentin his home was a physician, Robert Levet, who treated some of London's poorestfamilies. Another, Anna Williams, came initially as a visitor but ended upresiding in the Johnson home for 35 years. She was often irksome, but Johnsonenjoyed chatting with her over tea. She had cataracts and was treated by SamuelSharp, a surgeon at Guy's Hospital who was an important pioneer in the historyof cataract extraction. Two of his articles on cataract surgical techniquewere published by the Royal Society, and the composer Handel consulted himabout his cataracts. Sharp operated on both of Mrs Williams' cataracts, but"the crystalline humor was not sufficiently inspissated for the needle totake effect."17 She became blind and was Johnson'sresponsibility for the rest of her life.
Johnson was interested in the cataract problem of another friend, BennetLangton. He wrote,
I am very sincerely solicitous for the preservation or curingof Mr Langton's sight, and am glad that the chirurgeon gives him so much hope.Mr Sharp is of the opinion that the tedious maturation of the cataract isa vulgar error, and that it may be removed as soon as it is formed. This notiondeserves to be considered; I doubt whether it be universally true; but ifit be true in some cases, and those cases can be distinguished, it may savea long and uncomfortable delay.6(p357)
Johnson did not discuss cataracts with one of the most famous ophthalmologistsof the day, Chevalier Taylor, oculist to the king, who was a skillful surgeonbut also one of the most notorious quacks in the history of medicine.18 Johnson considered Taylor "the most ignorant manI ever knew," probably because he could not converse in Latin.9(pp289,290) He also said of Taylor, undoubtedly due to his outrageousbehavior, that he was "an instance how far impudence could carry ignorance."9(p291)
Johnson once commented, "It matters not how a man dies, but how he lives."10(pp106,107) His own life, however, wasmade difficult by physical disabilities. Late in life he wrote, "My diseasesare an asthma and a dropsy, and, what is less curable, 75."1(p363) Had he lived 2 centuries later, he would have found that goodhealth, which he considered the basis of happiness, was much easier to attain.
As Boswell wrote,
Such was Samuel Johnson, a man whose talents, acquirements, andvirtues, were so extraordinary, that the more his character is considered,the more he will be regarded by the present age, and by posterity, with admirationand reverence.1(pp429,430)
Correspondence: James G. Ravin, MD, MS, Medical College of Ohio,3000 Regency Ct, Toledo, OH 43623 (email@example.com).
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