In praise of the literary eponym--Henry V sign.

The use of eponyms in medicine is often discouraged. However, the literary eponym should be an exception as it is not linked with many of the difficulties associated with conventional eponyms and offers descriptive brevity and accuracy. Here, we illustrate the point with Henry V sign, which will be familiar to many who have cared for patients in the terminal stage of illness.

The use of eponyms in medicine has been much debated, defended and disparaged. Once intended to honour original discovery, eponyms may outlive their purpose, be overtaken by new information and are often misattributed. For example, the two co-authors on Crohn’s famous report are seldom mentioned, but does it matter if they only re-discovered what Dalziel had described earlier? What of the honour? Fine for Willis and his circle, or Broca high in the brain, but does anyone truly envy Bartholin the dubious accolade of linkage forever with his accursed cyst! Worse still, are the tainted eponyms inadvertently celebrating alleged racists and Nazi sympathizers., In response, some say banish eponyms in favour of more descriptive terminology. However, complex entities are seldom amenable to pithy descriptors. Fallot is probably secure because there is no simple way to describe the anomalies of his tetralogy. Abandoning traditional eponyms in medicine would not be easy and could create dangerous confusion. What jawbreaker would replace Hodgkin and the non-Hodgkin lymphomas?

Accuracy, even at the expense of brevity, is preferred in medicine, but a literary eponym can provide both. The literary eponym fulfils a mnemonic function, adds cultural perspective and flavour and is unlikely to become tainted. It can also portray complex traits and behaviour with economy of words.

A curious physical sign, recognized for centuries in literary and artistic works, which will be familiar to experienced clinicians, but not by name, illustrates the wisdom of an occasional literary eponym (Figure 1). Continual grasping or fumbling with bed clothes, seemingly for some imaginary substance, is often observed in seriously ill or delirious patients and in those otherwise close to death. Most often seen by physicians caring for the terminally ill, the sign is typically exhibited by patients who are within days or hours of death. It is known by the cold words, carphology (picking at bed clothes) and floccilation (picking at imaginary objects). We contend that the literary eponym, Henry V sign, is more descriptive, memorable, warmer to the sensitive ear and more. The senior author (J.C.M.) first heard of Henry V sign as a trainee over 30 years ago, but found no reference in medical literature. In contrast, the sign was well known to Shakespeare, Flaubert and Tolstoy. Indeed, most of the great writers had much to say about doctors, diseases, life and death.

Figure 1

Henry V sign.

Four hundred years ago, William Shakespeare knew that disorientated fumbling with bed clothes heralded death. Mistress Quickly announces the death of Falstaff, stating that she saw him ‘fumble with the sheets and play with flowers and smile upon his fingers’ ends’ and that she ‘knew there was but one way’ (Shakespeare W. Henry V, Act II, Scene III.). Prior to the publication of this, Shakespeare had moved from Stratford and lived in London during the plague epidemic of 1591 and 1592 when many of London’s population died, and he must have witnessed many deaths at close quarters.

Gustave Flaubert, a surgeon’s son also knew the sign heralded imminent death, and in 1857 in Madame Bovary, eloquently described Emma on her death bed: ‘Emma, her chin sunken upon her breast, had her eyes inordinately wide open and her poor hands wandered over the sheets with that hideous and soft movement of the dying, that seems as if they wanted already to cover themselves with the shroud’. Emma committed suicide by taking arsenic.

Leo Tolstoy recorded the same sign in Anna Karenina published in 1878. The death of Levin’s brother Nikolai from tuberculosis is predicted by Maria Nikolayevna: ‘he has begun picking at himself’, as if pulling at the folds of a woollen dress. Levin had notices how all day ‘the patient kept clutching at himself as if trying to tear something away’.

The portrayal of grasping at bed clothes has been recognized by others as a common deathbed scene; it has appeared in other literary works and in works of art, the most notable example of the latter being that of Francisco Goya’s Self portrait with Dr Arrieta in 1820.

Why name this simple gesture? Does it matter? What matters, to borrow from George Orwell, are ‘individual relationships, and a completely helpless gesture, an embrace, a tear, a word spoken to a dying man, could have value in itself’. In the cold impersonal arena of evidence-based everything, a literary eponym can humanize, lend familiarity and personalize the medical encounter, for the carer and for the patient.

Conflict of interest: None declared.