Clinical Negligence Ep 1: The Tragic Case

Doctors play a crucial role in society, forming the backbone of most medical systems worldwide by directly administering essential medical care. This reliance places a heavy responsibility on doctors, one with severe consequences for the patient if medical practitioners are derelict in their duties. In this article series, we explore the definitions and origins of negligence, and analyse how negligence occurs in the medical context.

It is startling now, but negligence, let alone medical negligence, was not a tort liable to legal prosecution just over a hundred years ago in the 1920s. This meant that doctors were often able to engage in questionable medical practices and escape professionally without sustaining any damage to their reputation. This is tragically exemplified in Shewry v. Maybury 1929, involving the plaintiff patient Leslie Shewry and the defendant doctor Dr Lysander Maybury.

On 20 July 1920, Leslie Shewry was born to Marcus and Charlotte Shewry, with an abnormal rash in his buttock area. Upon observing this, Leslie’s attending doctor Dr Maybury allegedly diagnosed him with congenital syphilis. While this may not seem out of the ordinary, Dr Maybury’s next actions are where the troubles begin. Not only did he not disclose this diagnosis to his parents, Dr Maybury also told them that Leslie had contracted jaundice instead before administering injections of “a liquid” into his brain’s blood vessels. This liquid turned out to be novarsenobilion (NAB). Injecting NAB in such a manner was, at that time, considered an acceptable method to treat syphilis. It has since been long phased out due to its significant toxicity caused by NAB’s arsenic content. For context, arsenic poisoning from contaminated water kills 9136 people yearly in Bangladesh now. Needless to say, the odds of having arsenic-related complications from an arsenical treatment like NAB being directly injected into your bloodstream are much higher than getting such complications from consuming contaminated water.

Even without the power of hindsight, Dr Anne Hanley remarks that it was “widely regarded [at that time] as especially dangerous and difficult” and had “fallen into disrepute” due to its unacceptably high risk of brain injury. In addition, NAB was very new in the 1920s when Dr Maybury started the treatment, hence prone to safety lapses in administration. After all, the blood vessels in the brain maintain the highly regulated blood-brain barrier to provide the specialised environment for neurons in the brain to function. These neurons, in turn, form the central nervous system, which controls conscious actions carried out by the body. Any damage to these blood vessels could have debilitating consequences for the patient.

To compound matters, Dr Maybury was no expert, but rather just a general practitioner with a rather spotty track record in medical practice. From dislocating the shoulder of his patient resulting in him becoming “gravely handicapped”, to falsely claiming to follow respected neurologist Dr Harry Campbell’s guidelines on injections of NAB (he did not, and even if he did, the injections by Dr Campbell were performed intramuscularly rather than into the brain’s blood vessels).

His choice of blood vessel was also questionable, at best. The longitudinal sinus (which refers to the superior sagittal sinus and the inferior sagittal sinus in the image, we will be using these terms interchangeably), Dr Maybury’s chosen injection site, are significant blood vessels essential to the brain’s function.

The superior sagittal sinus, in particular, is prone to thrombosis, which is the clotting of the blood vessel due to blood coagulation. This results in “irreversible consequences” that could result in “life-threatening conditions”, as claimed by Dr Vijay Letchuman and Dr Charles Donohoe from University of Missouri-Kansas City. A course of weekly injections to a particularly vulnerable blood vessel surely spells disaster, right? Especially since Dr Maybury noted that Leslie had convulsions after each injection?

And disaster it did cause. In no time, Leslie developed thrombosis of his superior longitudinal sinus, the same blood vessel that we warned about earlier, resulting in permanent physical and mental disability. Marcus Shewry, being treated for lung cancer and on his last days, began proceedings against Dr Maybury.

This moment is a good time to take a pause from the main narrative. Remember the NAB injection? That was to treat Leslie’s congenital syphilis, or so it was believed. However, Dr Maybury told Leslie’s parents he had jaundice, not congenital syphilis. While the rash is indicative of both conditions, and the former is a symptom of the latter, the treatment plans for the two conditions are diametrically opposed to each other. Herein lies the fundamental question: did Leslie actually have congenital syphilis?

From Dr Maybury’s subsequent statements, it is safe to believe that Dr Maybury’s defence relied on his syphilis diagnosis as the only reasonable one that an experienced doctor may arrive at. This leaves the question of why Dr Maybury lied to Leslie's parents unresolved, and is altogether rather unconvincing at first glance. This narrative is also at odds with the established medical understanding of congenital syphilis at that time.

As early as the 1870s, the symptoms of congenital syphilis were understood to be late-onset, appearing only a few weeks after birth. Dr Maybury claimed that the jaundice was indicative of syphilis, which might not be wrong but fails to account for the fact that it is also a common condition amongst healthy newborns. To contextualise this, according to Kandang Kerbau Women’s and Children Hospital (KKH), in 2018, 60% of full-term babies, and 85% of premature babies were diagnosed with jaundice, while a singular case of congenital syphilis was reported. Even in the late 19th century, physicians noted jaundice to be a “generally benign and self-limited” condition, as Dr William Cashore notes. In light of this knowledge, Dr Maybury insistence that Leslie’s jaundice was a justifiable reason to suspect he had syphilis is even more inexplicable.

Leslie’s lack of other symptoms of syphilis was also suspect. In a syphilitic rash, the patient’s palms and soles of his feet should be affected as well. This was not observed in Leslie. In fact, a few telltale signs of congenital syphilis were missing, including a pot belly, withered skin, and a prematurely aged and wrinkled face. Also unusual was the rash itself, which was observed as scaly. This was unusual for a syphilitic rash, which should have peeled off to leave the raw skin exposed. In fact, it was increasingly looking like natural irritation from faecal and urine contact rather than a syphilitic rash. Dr Thomas Ballard postulated that many infantile genito-anal rashes were not pathological at all. He later adds that it is “a strange perversion of reasoning …… that the disease (syphilis) must have a natural habitat in those regions’ among infants” since it was a sexually transmitted disease in adults.

The clincher lies with one of Dr Maybury’s key witnesses, Dr Richard Macpherson, the Medical Superintendent of the Portsmouth Infirmary. While he aligned with Dr Maybury’s view that Leslie had congenital syphilis, he reported under his own care several children with effectively identical symptoms that had never been exposed to NAB, let alone injected into the brain’s blood vessels. This inadvertently demonstrated that Leslie’s symptoms could be caused by conditions other than congenital syphilis. Bizarrely, Macpherson testified that Leslie had ‘a typical case of Little’s disease’, which is a form of infantile cerebral palsy and definitely not congenital syphilis.

By now, Dr Maybury’s defence should be lying in tatters and this should have been an easy win for the Shewrys. Unfortunately, it was not to be. Public media, as per convention at that time, sided with Dr Maybury as “gentlemen of high position in the profession”, as was considered of all doctors regardless of previous track record. It was also standard practice to favour defendants in negligence cases as the reporters, often medical professionals themselves, viewed them as their “fellow doctors”. To them, it seemed ludicrous that 12 laymen (i.e. the jury) without medical training were given authority to pass judgement on a qualified medical professional’s diagnosis and treatment. Any judgement that contradicted Dr Maybury’s position was heavily lambasted, with many reporters claiming that emotions had clouded that decision.

Hence, with the help of social conventions, Dr Maybury was able to gain full control of the narrative. From micromanaging various witness statements to preparing key witnesses with pre-prepared questions and answers to face cross-examination, he heavily influenced, and even manipulated, the perceptions of his case to suit his interests. As he was a police surgeon regularly called upon to provide evidence, he understood and was able to manipulate court processes to his advantage, aided by a compliant system and social norms that worked in his favour. These conditions ultimately allowed him to choreograph his defence as the medical profession closed ranks around him.

Hence, in spite of all the biological evidence stacked against his diagnosis, without any sound biological reasoning backing his medical treatment, and even with his witnesses occasionally contradicting his narrative despite his best efforts to micromanage their statements, Dr Maybury was let off scot-free.

If the Shewrys were in bad shape before trial, they were practically ruined by its conclusion. Leslie had died 13 days before the final judgement, and Dr Macpherson registered his death under four causes, one of which was the aforementioned Little’s Disease. There was no mention of congenital syphilis in his cause of death. It was Marcus Shewry’s turn to die a few weeks later. Already too sick to attend court and fully cognisant of his impending demise, he had hoped that damages from a favourable verdict would help fund Leslie’s future endeavours. Not only were no damages awarded, the person who the damages was supposed to aid was long gone.

As Dr Hanley concludes, “it is likely that Maybury had not intended to harm Leslie” but rather to “prevent distress”. That being said, his actions set forth a chain of events that harmed the Shewrys, and his subsequent machinations were motivated by his desire to preserve his reputation and achieve a favourable outcome, irrespective of whether he had incurred more harm on the Shewrys. At the individual level, Dr Maybury’s ego resulted in him exploiting his professional status to justify working beyond his true abilities, causing grievous harm to Leslie and the Shewrys. However, when taken in context, Shewry v Maybury was emblematic of the flawed nature of the medical practice, as it sought to inflate Dr Maybury’s credentials and deny his patient’s experiences even if they were backed by scientific fact.

It would not be until 1932 when a seismic shift would ameliorate this situation, aided by a bottle of ginger beer, a decomposing snail, and one very angry woman. Although this development would be too late for Leslie Shewry, it has had and continues to have a meaningful impact in the prosecution of medical negligence cases today. Stay tuned for the next issue as we explore a landmark case in negligence.

References:

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2. Hanley, A. (2024). ‘We all of us make mistakes’: Medical negligence in interwar general practice. Social History of Medicine. https://doi.org/10.1093/shm/hkae097

3. Papers of Felix Eberlie Regarding the Case of Shewry v. Maybury 1929: A Case of Alleged Medical Negligence. (n.d.). Wellcome Collection. https://wellcomecollection.org/works/cjadukh5

4. Galea, I. (2021). The blood–brain barrier in systemic infection and inflammation. Cellular and Molecular Immunology, 18(11), 2489–2501. https://doi.org/10.1038/s41423-021-00757-x

5. Letchuman, V., & Donohoe, C. (2023, January 23). Neuroanatomy, superior sagittal sinus. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK546615/#:~:text=Clinical%20Significance,nasal%20sinus%20infection.%5B2%5D

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7. Communicable Diseases Division, Ministry of Health, Singapore. (2018). Communicable Diseases Surveillance Singapore 2018. https://isomer-user-content.by.gov.sg/3/76c9cb21-38c5-4180-871e-665b4762dd3e/communicable-diseases-surveillance-in-singapore-2018.pdf

8. Wilkins, R. H., & Brody, I. A. (1969). Little’s disease. Archives of Neurology, 20(2), 217. https://doi.org/10.1001/archneur.1969.00480080117014

9. Lokuge, K. M., Smith, W., Caldwell, B., Dear, K., & Milton, A. H. (2004). The effect of arsenic mitigation interventions on disease burden in Bangladesh. Environmental Health Perspectives, 112(11), 1172–1177. https://doi.org/10.1289/ehp.6866

10. Cashore, W. (2010). A brief history of neonatal jaundice. In MEDICINE & HEALTH /RHODE ISLAND (Vols. 93–93, Issue 5). http://www.rimed.org/medhealthri/2010-05/2010-05-154.pdf