Background: Neurology and literature have a complex interface; one of the facets is that of works inspired by grief on the passing of a beloved one due to a neurological disease. Summary:In Memoriam A.H.H., written by Alfred Tennyson and published in 1850 in response to the untimely death of Arthur Henry Hallam, is one such elegy, which had a profound impact in Tennyson’s body of work and on the history of Victorian poetry in general. In this review, the author delineates biographical notes of both men before analyzing the disease and death of Arthur Hallam due to hemorrhagic stroke. Key Messages: By evaluating Hallam’s autopsy report and contemplating the different hypotheses on the etiology of his stroke, as well as how his death due to catastrophic neurological disease was memorialized in verse, neurologists may gain better insight on the interface between neurology and literature inspired by grief.

The complex interface between medicine and literature has long been explored and can be understood through different facets [1, 2]. Going beyond the acknowledgment of writers who were also physicians, such as William Somerset Maugham (1874–1965) [3] and Arthur Schnitzler (1862–1931) [4], it is possible: (a) to study the diseases that affected writers, poets, and playwrights and analyze how they influenced their creative output, both in terms of quantity and content, as well as investigate the diseases that caused the often untimely death of these authors; (b) to study mentions of signs, symptoms, or explicitly named pathological entities in the characters of their writings; (c) to study more broad literary considerations and observations on the nature of diseases or medical interventions, in literal or metaphoric fashion; (d) to analyze literature that has been written as response to the disease or loss of a beloved one, in an elegiac fashion, be the disease explicitly named or not.

Examples for each category abound; for the first one, one may find examples ranging from the lyrical cries for deliverance from disease present in King David's forty-first psalm [5], in the 10th century BC, to Stendhal (1783–1842), Ralph Waldo Emerson (1803–1882), and Charles Baudelaire (1821–1867), all victims of stroke leading to aphasia [6]; for the second one, one may be reminded of William Shakespeare’s (1564–1616) enormous canvases of mental illness, epilepsy, and congenital abnormalities [7], among others, or Thomas Mann’s (1875–1955) exquisite characters struggling with cholera, neurosyphilis, and tuberculosis [8]; for the third one, consider Ovid’s (43 BC-17/18 AD) mention of surgery in book I of his Metamorphoses, in 8 AD [9], Geoffrey Chaucer’s (circa 1,340–1,400) Canterbury Tales and his considerations on the still quasi mystical medicine of his age [10], and Thomas Stearns Eliot’s (1888–1965) recurring images of nerves, brains, or skulls [11]. In short, many authors have been drawn toward the realms of disease and medicine and have sought ways to describe, deal with, or interpret the sufferings and pains borne from them.

However, not all poetry or literature related to medical themes relies on direct mention of pathological entities, thus leading to the aforementioned fourth category: a subtle relationship between literature and medicine understood in terms of poetry or prose inspired by grief, an attempt to come to terms with death or suffering without dissecting the specific medical cause; id est, a study of the consequences of disease, not of disease itself. In this latter category, few poetic compositions have the same visceral intensity as Alfred Tennyson’s (1809–1892) In Memoriam A.H.H., first published in 1850 [12]. Although similarly passionate examples of elegies and memorials to the departed abound in English literature – one needs only to be reminded of The Wife’s Lament, from the tenth century’s Exeter Book [13], John Donne’s (1572–1631) satirical, yet love-torn elegies [14], John Milton’s (1608–1674) Lycidas [15], Percy Bysshe Shelley’s (1792–1922) Adonais [16], in memory of fellow poet John Keats (1795–1821), and William Wordsworth’s (1770–1850) Surprised by Joy, Impatient as the Wind [17]–, Tennyson’s work stands tall, rising from an initially anonymous publication to the prominent place it occupies now in the history of English poetry.

In the poem, Tennyson mourns the passing of his friend Arthur Henry Hallam (1811–1833), who, only 2 years his junior, died victim of an “apoplexy”; i.e., what is now understood as a stroke. The younger poet had become Tennyson’s friend while both attended the University of Cambridge. His early death interrupted a promising career and devastated Tennyson, who took more than a decade to compose and collect the poems that would become In Memoriam [18]. In this review, the author traces brief biographical notes on both poets before analyzing the case of Arthur Hallam and how his death due to neurological disease was memorialized in verse.

Alfred Tennyson, first Baron Tennyson, was born into a middle-class family in Somersby in 1809. He studied at Trinity College, a constituent of the University of Cambridge, where he joined a fellowship called Cambridge Apostles, likely at Hallam's invitation [19]. He first published Poems by Two Brothers in 1827, working with his brothers Frederick (1807–1898) and Charles (1808–1879), who was actually the author of the majority of the poems in the compilation [20]; this early work was followed by Poems, Chiefly Lyrical, from 1830 [21]. His friendship with Hallam was consolidated on trips to continental Europe; after Hallam’s catastrophic death in 1833, Tennyson started writing the fragments that would eventually constitute In Memoriam [22]. Poems, dated 1833, included some of his most famous short pieces, including The Lady of Shalott and The Lotos-Eaters [23]. The year 1842 saw the publication of the equally famous Ulysses and Morte d’Arthur, the seed of Idylls of the King [24]. ThePrincess [25] followed in 1847, as did In Memoriam [12], finally published in 1850; in the same year, Tennyson married Emily Sellwood (1813–1896) and was appointed Poet Laureate of the United Kingdom by Queen Victoria (1819–1901), succeeding William Wordsworth [19]. Another notable elegy, Ode on the Death of the Duke of Wellington, and The Charge of the Light Brigade followed in 1852 and 1854, respectively [26]. His fame grew to the point of being called on by Prince Albert (1819–1861) on the Isle of Wight in 1856 [19], 1 year after publishing Maud, and Other Poems [27]. His later years saw prolific work, such as The Holy Grail and Other Poems (dated 1870) [28]; upon his death, he was buried in the Poets’ Corner of Westminster Abbey [19]. He and Emily had two sons, Hallam (1852–1928), named after his late friend, and Lionel (1854–1886).

Arthur Henry Hallam, on the other hand, had a more privileged upbringing, first studying in Eton College before moving to Cambridge [29]. His friendship with Tennyson soon extended to an acquaintance between their families, to the point that Hallam became infatuated and romantically involved with Tennyson's sister Emilia (1811–1887), after a visit to Somersby in 1829; an engagement soon followed, to the chagrin of both their fathers. The poets planned to write volumes of poetry together, and it was Hallam who introduced Tennyson to publisher Edward Moxon (1801–1858), who would ironically be the one to print In Memoriam. Throughout his life, Hallam suffered with chronic headaches, as documented in numerous letters [18]. His Remains in Verse and Prose were edited and published by his father, comprehending poetry and essays [30].

Arthur Hallam and his father, Henry Hallam (1777–1859), historian and fellow Etonian, left England for a continental European voyage on August 3, 1832; both had bouts of Influenza earlier that year and were eager to have a restful trip [18]. By the 13th of September they had reached Vienna, intending to go to Prague. Their plan was thwarted by the development of fever and headaches by the former, perhaps already sentinel headaches; rest and quinine were prescribed. On the 15th, Henry left his son resting while he went on a walk; he returned to find Arthur motionless and unresponsive [18, 30].

After the death register by the Austrian authorities, his corpse underwent an autopsy, performed by Karl von Rokitansky (1804–1878), a pathologist and professor at the University of Vienna [18], and Jakob Kolletschka (1803–1847); Rokitansky released his report (shown in Fig. 1) on the 17th of September, in Latin, writing (all translations are by the author): “Ventriculi cerebri laterales drachmas circiter binas seri rubelli continebrant [the lateral ventricles of the brain contained about two drachms of reddish serum].” (…)“Omnis nervi cerebrales flaccidi inveniebantur, sinus dura matris sanguine spifso, turgidi et juga cerebralia hine indo spinose prominebant [all the cerebral nerves were found to be flaccid; the dura-mater sinuses were hardened and thickened with blood, and the cerebral juga protruded with prominent red].”(…)“Sinus falciformis largam sanguinis spissi, atro-rubri quantitatem continet [the falciform sinus contains a large quantity of thick, dark red blood].” (…)“Vasa pia meningis varicosa, anfractuose decurrentia, sanguine atro-rubro turgestentia deprehenduntun [The pio-meningeal vessels are varicose, running their course, displaying a dark-red, bloody turgidity].”(…)“Substantia cerebri mollior visa est, pastacea, sanguine largiter provisa, versus basim cerebri latire sero, so imbuta [the brain parenchyma is seem to be softer, pasty, with profuse blood supply; the basal surface of the brain is so imbued].” [31].

Fig. 1.

Autopsy report of Arthur Henry Hallam (Henry Hallam Collection, General Collection, Beinecke Rare Book and Manuscript Library, Yale University; used with permission).

Fig. 1.

Autopsy report of Arthur Henry Hallam (Henry Hallam Collection, General Collection, Beinecke Rare Book and Manuscript Library, Yale University; used with permission).

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The news was sent to Tennyson in October by Henry Elton (1786–1858), Arthur’s maternal uncle and a Navy captain, who narrated the death as such: “He died at Vienna, on his return from Buda, by Apoplexy, and I believe his Remains come by Sea from Trieste.”(…)“Poor Arthur had a slight attack of Ague - which he had often had - Order'd his fire to be lighted - and talked with as much cheerfulness as usual - He suddenly became insensible, and his Spirit departed without Pain - The Physician endeavour’d to get any Blood from him - and on Examination it was the General Opinion that he could not have lived long” [32, 33]. The description given by Henry Hallam, in the preface to the Remains in Verse and Prose, was similarly succinct: “a sudden rush of blood to the head put an instantaneous end to his life, on the September 15, 1833.”; he also commented on the autopsy, “which showed a weakness of the cerebral vessels, and a want of sufficient energy in the heart.” Hallam’s body, sent by sea, was buried in the family vault at Clevedon Church in 1834 [30].

It is worth noting that the term “apoplexy,” used since Hippocratic times, held a broad meaning that included both ischemic and hemorrhagic stroke through time [34, 35, 36]; Hermann Boerhaave (1668–1738), for instance, used the term to refer to “a stopping of the spirit” [37]; Giovanni Battista Morgagni (1682–1771) saw a distinction between “total” and “parcial” strokes, calling the former “apoplexy” and the latter “paralysis,” and between “sanguineous” and “serous” apoplexy [38]. Though distinctions had been made by Jean-André Rochoux (1787–1852) in 1814 [39] and Léon Rostan (1790–1866) in 1819 [40], a clearer division between apoplexia ischaemica and apoplexia sanguinea would be offered only later, in 1856, by Rudolf Virchow (1821–1902) [41]. Although the autopsy does not unequivocally describe a ruptured aneurysm per se, a Fisher grade 4 aneurysmal subarachnoid hemorrhage is a possible hypothesis, given Hallam’s young age, fast progression, lack of other known significant comorbidities, and extensive bilateral ventricular and basal inundation; hypotheses such as intraparenquimatous hemorrhage due to other etiologies are discouraged due to the absence of specific hematoma in either white or gray matter; other causes of abrupt subarachnoid hemorrhage, such as a ruptured arteriovenous malformation, tend to be more benign. Another plausible cause is cerebral venous thrombosis, due to the descriptions of varicose cortical veins and possibly thrombotic dura-mater sinuses, leading to hemorrhage.

No contemporary account of Tennyson’s reception of the news exists. In 1869, Emily Tennyson wrote in her diary [42] that Tennyson’s sister Matilda (1816–1913), upon returning from dancing lessons, picked up the post and delivered Elton’s letter to her brother. As she left to take off her bonnet, she heard the sound of Tennyson suddenly rising to his feet; he soon left to inform Hallam’s wife [42].

Hallam’s death scarred Tennyson for life: in 1854, in a letter to Edmund Lushington (1811–1893), the poet mused on how he had “spent some of the happiest days of my life with Arthur Hallam 25 years ago” [32]; Lushington married Alfred’s sister Cecilia (1821–1909), to whom the epilogue of In Memoriam, an epithalamium, is dedicated. As late as 1883, Tennyson still held his friend’s passing as a matter of utmost importance. Upon learning that James Knowles (1831–1908), editor of The Nineteenth Century, intended to publish Hallam’s letters, he wrote to William Gladstone (1809–1898): “Don’t let Knowles print A.H.H.’s letters – at least let them be first submitted to me. I think that I of all living men should be allowed a voice in this matter.” [18].

Published anonymously, In Memoriam A.H.H. was composed between 1833, right after Hallam’s passing, and 1850; it is not an uniform elegy, but a collection of 131 lyrical cantos of varying lengths, capped by a prologue and an epilogue, in stanzas of four octosyllabic verses rhyming abba [22, 43]. It expresses a wide range of feelings, from despair to anger to longing, by conjuring plenty of images, such as faith, including the invocation at the prologue (“Strong Son of God, immortal love,”…“in thy wisdom make me wise.”), and defiance toward naturalistic, reductionists views of nature in canto CXX (“I trust we are not wholly brain/Magnetic mockeries;”…“What matters Science unto men,/At least to me?”) [12, 43]. This particular stanza might also be a reference to the discredited theories on “animal magnetism,” or mesmerism, by Franz Mesmer (1734–1815), which had swept the United Kingdom in the preceding century [44].

In canto XC, Tennyson writes how “[he] tasted love with half his mind” and longs “[that] could the dead, whose dyingeyes/Were closed with wail, resume their life”; this yearning for immanence loses no power later as the poet cries: “Ah dear, but come thou back to me:/Whatever change the years have wrought,/I find not yet one lonelythought/That cries against my wish for thee” [12]. In canto XCIII, the poet sighs with resignation and seeks comfort in the spiritual plane: “Descend, and touch, and enter;hear/The wish too strong for words to name;/That in this blindness of theframe/My Ghost may feel that thine is near”; in canto XCV, Tennyson evokes his feelings upon rereading Hallam’s letters to him: “So word by word, and line by line,/The dead man touch’d me from the past”; he compares them to “fall’n leaves which kept their green,/The noble letters of the dead” [12].

As noted by Roberts, In Memoriam marked “a turning point in Tennyson’s life and poetic career”; the profundity of the grief gave the poet “a subject other than his own morbid subjectivity: the subject of loss” [43]. He moved from the “dissociated melancholia” of Mariana or Ulysses and moved toward a deeply felt response to death [43, 45]. In Memoriam, at the same time, symbolizes the preoccupations and pieties of the Victorian age (religion, science) while going beyond its conventions (the quasi-Romantic outpour of emotion) [22, 43, 45, 46]; such is the emotional intensity of the work that at least one contemporary critic believed the then-anonymous work had been written by a grieving widow [47]. The long composition of In Memoriam has itself been interpreted as a reflex of the extended grief of the poet, experienced in waves: canto LXXXV has been used as an example of this process: “Likewise the imaginative woe,/That loved to handle spiritual strife,/Diffused the shock thro'all my life,/But in the present broke the blow.” [12, 17, 48].

It is worth noting that In Memoriam was not the only work composed in Hallam’s shadow: In the Valley of Cauteretz, from 1861, evoques a trip to Spain [46]; Vastness, from 1885 [49], closes with “Peace, let it be! For I loved him, and love him for ever:/the dead are not dead but alive.

Perhaps one of Tennyson’s most endearing homages to his friend’s passing was in the naming of his own son: Hallam Tennyson. In a letter to Aubrey de Vere (1814–1902), before the infant was born, he writes: “You ask what his name is to be. My wife sticks out for Alfred (…) to which I cannot resist my desire to add the name of my old friend Hallam.” [42].

In Memoriam A.H.H. fully encapsulates the aforementioned subtle relationship between literature and medicine in terms of poetry inspired by grief, thus being a study of the ultimate consequence of disease, not a simple description of disease itself. A catastrophic neurological disease, whose prognosis is today almost as dire as it was in the Victorian age, led to an untimely death, which, in turn, inspired an outstanding literary work. As previously argued by the same author [50], neurological diseases and the suffering borne from them, though often conflated solely with limitations on the artistic output of ill or grief-stricken artists, may also serve as a source of change, helping the definition of a new artistic voice or style, and, thus, indirectly serve as a pivotal force to higher artistic aspirations and creations.

The author thanks the Beinecke Rare Book and Manuscript Library, Yale University, for permission on the use of Hallam’s autopsy report.

This paper required no authorization from an Ethics Review Board due to its historical nature.

The author has no conflict of interest in this paper due to its historical nature.

This paper had no funding due to its historical nature.

M.K.F.P: research and manuscript composition.

All the data generated for this paper is contained above.

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