The near-death of the novelist
Virginia Woolf’s Veronal overdose, 1913 – by Ian Franklin
Two men rushed out of a front door and hailed a taxi outside 38 Brunswick Square in Bloomsbury, central London, on 9 September 1913. They were on a medical emergency. It was essential to collect and return with a stomach pump from St Bartholomew’s Hospital about half a mile away. Their patient, Virginia Woolf, was at death’s door. She was not yet the famous novelist, but this was her first serious suicide attempt and it required an urgent medical intervention.
Dr Geoffrey Keynes, house surgeon at St Bartholomew’s, accompanied Leonard Woolf, Virginia’s distraught husband. Virginia was a gifted individual who had only started her writing career, completing but not yet publishing The Voyage Out. Already, though, she was disturbed by mood swings that sometimes felt overwhelming; on this particular night, she needed urgent professional help to prevent the risk of a fatal outcome. Had she not received it, the rest of her famous novels might never have been written. In later life, Keynes liked to think that he had saved her future masterpieces for posterity. Sadly, these mental ill-health episodes would continue, culminating in her death by suicide during World War II. Virginia’s medical case notes illuminate how well strong barbiturates were understood on the eve of World War I, before the mental traumas of the trenches.
Virginia Woolf’s medical history reveals that she had been unwell for some months earlier in 1913. She had experienced episodes of hypomania in the past, and would do so again, but the problem in the summer and autumn of 1913 was the start of what today would be termed clinical depression. She had been referred to a neurology specialist called Sir George Savage, who worked with private asylum patients and had a reputation for rescuing difficult mental health cases. He had recommended peace and quiet, as well as physical rest and an eating treatment, and he gave her a new sleeping draught to help with her insomnia. This regimen had been taken very seriously by Leonard, whom Virginia had married the previous year, and they had been following Savage’s treatment plan assiduously. However, while they respected Savage, they were not convinced that his holistic prescription was working. So she came to London to seek a second medical opinion. On the recommendation of Roger Fry from the Bloomsbury Group she visited Dr Henry Head, an eminent neurologist and experimental scientist. Head was already a Fellow of the Royal Society, and would be knighted in 1927.
Leonard and Virginia saw Head on the afternoon of Tuesday 9 September, just hours before her first suicide attempt. Leonard gives some idea of the seriousness of her condition in his autobiography, Beginning Again, when he wrote that the day before: “Virginia was in the blackest despair and there was, I knew, danger that she might at any moment try to kill herself by jumping out of the train.” After the appointment with Head, Leonard went to see Savage to advise him that they were consulting Head. Meanwhile, Virginia returned home, where a friend – Katherine (‘Ka’) Cox – had agreed to keep an eye on her. At about 6.30pm Leonard received a telephone message informing him that Virginia had fallen into a deep sleep. She had taken an overdose of a new brand of sleeping drug called Veronal, manufactured from barbitone (first synthesised in 1902 by German chemists Emil Fischer and Joseph von Mering). Generally it was dispensed for insomnia induced by what was then called nervous excitability. The patient was given a capsule or sachet with water at bedtime, and a therapeutic dose was 15 grains (just under 1 gram). Clearly, Cox’s eye had not been keen enough, for Virginia managed to ingest 100 grains of Veronal – a potentially fatal amount.
By the time that Leonard and Dr Geoffrey Keynes returned from St Bartholomew’s with a stomach pump borrowed from the emergency room, Head had also arrived with a nurse. The two medical men got on with the assembly and use of the apparatus. Keynes’s own account, in Gates of Memory, states that they worked through the night, though it is unclear from the family records how long the ‘pumping’ of her stomach went on for. At one point, it looked doubtful that Virginia would survive the night because her pulse was so weak. Hermione Lee’s biography of Virginia stresses that at around 1.30am she looked dangerously ill. By daybreak, however, she was stronger and clearly out of danger, although she did not wake up fully until the following day, Thursday.
Although Leonard normally kept the drugs case locked, he inexplicably failed to do so on this occasion. Ka Cox did her best – she was not a trained nurse or doctor – but Virginia managed to elude her. Cox seemed a very popular member of this circle. Michael Holroyd in his life of Lytton Strachey quotes a letter from Strachey at the time of Virgina’s suicide attempt. “Poor Woolf!” he writes – meaning Leonard. “Nearly all the horror of it has been and still is on his shoulders. Ka gave great assistance at the worst crisis…” It seems Ka was not blamed by anyone for this incident.
One hundred years on from the drama of that night, we can ask: how effective was their intervention was in its historical context, and how have things changed in the intervening century?
At the time there were a number of leading medical journals that considered Veronal to be an effective drug for mental health patients with persistent insomnia, but all warned that it should be taken in moderation. In March 1913, the British Medical Journal had published a leading editorial entitled ‘Veronal Poisoning’, which was read widely. It contained details of a suicide inquest at Hove in Sussex, which had attracted a lot of adverse publicity because the deceased had been given Veronal. Hugh Eric Trevanion had taken 150 grains 32 hours before he died, and so the jury had advised in their concluding verdict: “That Veronal, its derivatives and allied substances should forthwith be placed on the poisons schedule – That it be illegal to supply any hypnotic drug without the prescription of a medical man.” The California State Medical Journal described that there could be after ingestion a downhill course to death. If the patient looked in danger then a gastric lavage (stomach pump) was essential, followed by the introduction of black coffee and one egg into the stomach. Only two weeks after the BMJ article, Goldney Chitty wrote in the Lancet about a recovery following 125 grains of Veronal poisoning, with gastric lavage being undertaken over the 12 hours after ingestion, with coffee and egg being left in the stomach. Poisoning with Veronal was evidently highly topical in 1913, and this type of commentary suggests that Doctors Keynes and Head, and likely most general practitioners, would have been familiar with the basic emergency procedure given to Virginia.
In Virginia’s case, she was treated in a professional manner by the doctors. The stomach pump procedure would have been necessary but very unpleasant to administer and experience even in a drowsy state. After gastric lavage a pint of strong coffee and some castor oil were left as an aperient in the stomach. Stimulants such as caffeine and strychnine were also sometimes part of the management of Veronal poisoning, as was digitalin: although no mention of the use of these is made in Virginia’s case.
In 1966, Henry Matthew and colleagues from the Poison Centre and University Department of Clinical Chemistry at the Royal Infirmary in Edinburgh, writing in the BMJ, argued that lavage could be worthwhile in barbiturate poisoning, but only if performed quickly. They found that lavage within four hours of ingestion removed over 200 mg of barbiturate from the stomach a third of the time, but beyond that point such efficacy was extremely rare. Barbiturates were widely used in the first half of the 20th century as a treatment for epilepsy and as hypnotics – essentially sleeping tablets for insomnia. Phenobarbitone was the most widely prescribed until all barbiturates were phased out in the UK during the 1960s because people were becoming habituated to them – and also because of their use in suicide attempts. Barbiturates continue to be used widely in developing countries.
The current management of a barbiturate overdose, most commonly with phenobarbitone, does not include gastric lavage. It was however a regular part of the management of self-poisoning into the 1980s, as ubiquitous and often useless as the ‘psychs to see’ referral – medical jargon for a request for a psychiatrist’s opinion. The stomach pump seemed to be a disincentive to repeat the overdose habit, rather than something that was felt to be life-saving. In 1996, three doctors in the Accident & Emergency Department of Hull Royal Infirmary (Greaves, Goodacre and Sprout) reported the results of a survey of 190 other doctors in A&E in the UK. Their results suggested that “‘punitive’ washouts may still be taking place despite a lack of clinical indication”. A systematic review from 2011 by two doctors at the Royal Brisbane and Women’s Hospital in Australia (Roberts and Buckley) suggested that there was little in the way of proven therapy, although supportive care and multiple doses of activated charcoal (MDAC) seem usual. The use of MDAC is recommended only after securing the airway, usually with a cuffed endotracheal tube.
This was not available in Virginia’s case: Ian Magill did not invent the soft endotracheal tube until 1919, and cuffed endotracheal tubes were not in use until 1931 or 1932. She had to endure gastric lavage, which would have been particularly hazardous, with the risk of aspiration of gastric contents or lavage fluid, and subsequent pneumonia. In the pre-antibiotic era this could have grave consequences. Despite the danger, though, Doctors Keynes and Head did exactly what contemporary medical opinion would have held them to do in this case. The fact that Virginia made repeated suicide attempts despite the very harrowing nature of gastric lavage tells us just how disturbed her mind became. They believed that gastric lavage was necessary even though in all probability its side-effects risked endangering her life.
It is intriguing that of all those involved in Virginia Woolf’s first suicide attempt, one or two became famous, and others achieved career success but sank into obscurity. Sir Henry Head is remembered today in part as a minor character in Pat Barker’s Regeneration trilogy of novels but in medical circles is praised for his seminal work with Dr William Rivers on peripheral nerve innervation. Sir George Savage by contrast is largely forgotten, although evidently Virginia overcame her earlier doubts about his treatments, because she attended his practice on and off over the next decade. Ka Cox is only remembered as the lover of Rupert Brooke; Sir Geoffrey Keynes had proposed marriage to her in 1912 and did so again in 1914, but she turned him down on both occasions. He went on to become an eminent surgeon and man of letters. Leonard Woolf and Roger Fry are still renowned as members of the Bloomsbury Group. Virginia Woolf towers, however, above them all. Whether or not Keynes was correct in his belief that he had saved her (and her future masterpieces) we cannot truly know, but it seems likely that the presence of such a dynamic and decisive young doctor would have been hugely reassuring to the group at 38 Brunswick Square. With his and Head’s help, this promising young writer survived that night, and when eventually she did die, it was the death of a great novelist.
Professor Ian Franklin is a haematologist and has worked in Birmingham, Glasgow and Dublin. He has recently retired as Medical and Scientific Director of the Irish Blood Transfusion Service and previously was in a similar post in Scotland. He is Emeritus Professor of Transfusion Medicine in the University of Glasgow and welcomes enquiries about his research (firstname.lastname@example.org).