Oscar Wilde has always been beset by gossip, scandal, and myth making, as much posthumously as during his lifetime. Even as late as 1987 his best biographer to date, Richard Ellmann, reproduced a photograph purporting to be Wilde in drag as Salomé, but which turned out to be a Hungarian soprano at the Cologne Opera in 1906. The imprecise cause of Wilde's death, too, has led to much ink being spilled over the years, although in November, 2000, the centenary of Wilde's death, a piece was published in The Lancet that re-examined the nature of his terminal illness, dispelling most of the mythology. However, the unexpected death at the age of 40 years of his wife, Constance, who had been suffering from a neurological disorder for about 10 years beforehand, has never been satisfactorily explained. We are now able to unravel the mystery, largely through new insights contained in private family papers held by Merlin Holland, grandson of Constance and Oscar Wilde.

Born in London on Jan 2, 1858, Constance Lloyd married Oscar Wilde in 1884 and had two sons in 1885 and 1886. After Oscar's conviction and imprisonment for homosexual acts in May, 1895, she and the children fled to Europe to escape the backlash of his scandal, changing their surname to “Holland”, an ancestral family name already adopted by her brother, Otho, who was avoiding creditors after financial difficulties. After a peripatetic existence she eventually settled at an Italian coastal village, Bogliasco, close to Genoa. Throughout her exile Constance was afflicted with ill health, in addition to the burden of single parenthood in a foreign environment.

Constance was a minor celebrity in her own right. Well educated and articulate, she contributed to newspapers and journals, edited a periodical on dress reform, and published two books of children's stories as well as an anthology of her husband's epigrams. She also participated actively in the Liberal politics of the day.

Her ill health dates from about 1889 when she experienced lameness in her right leg and required a stick for support. In March that year she spent 10 days in Brighton recuperating, but from June to August had a relapse. Thereafter she remained fairly well until late 1891, when she was often incapacitated, and sometimes bedridden, by bouts of severe pains, especially affecting the arms, which she called “rheumatism”. Recovery ensued, but by February, 1893, she was debilitated by pains in her head and back, described by her as “neuralgia”.

A fairly long period of reasonable health followed until she had a serious relapse in the winter of 1894–95 when she wrote: “I am alright when I don't walk, but then I can't go thro' life sitting on a chair especially with two boys to amuse.” Her mobility problems continued until March, 1895, but throughout the subsequent trying months that coincided with Oscar's trials and imprisonment she made no further reference to her illness.

At the end of 1895 her walking had again deteriorated with marked limitation on her activities. By then in Italy, Constance consulted the gynaecologist Luigi Maria Bossi (1859–1919), who “undertakes to make me quite well in six weeks and I shall be glad to be able to walk again”. In December she spent a month in his private clinic in Genoa, undergoing major and costly surgery, the nature of which is unclear from her correspondence at the time. Her improvement was short-lived, and in April, 1896, she wrote: “I am lamer than ever and have almost given up hope of ever getting well again.” She sought help from an unnamed “nerve doctor” in Heidelberg, Germany (where she was residing temporarily), who prescribed a hotchpotch of treatments then in vogue, including baths and electricity.

All these therapeutic manoeuvres failed, and by October, 1896, in addition to the persistent lameness of her leg, a tremor appeared in her right arm. This so disrupted her handwriting that she was eventually forced to use a typewriter. “I am tired of doctors and no doctor finding out what to do with me,” she lamented. Moreover, she suffered protracted and excruciating headaches as well as extreme fatigue brought on by the mildest exertion. This was observed by her brother who, in July, 1897, noted that after only a few minutes' walk to the station she collapsed on the road from exhaustion and had to be dragged to safety. And, if this was not enough, she developed a left facial palsy towards the end of her life.

According to the unpublished correspondence of Constance and her brother, her 9-year illness was characterised by widespread pains, right leg weakness, tremor of the right arm, profound fatigue, and a left facial paralysis. For the first 7 years the clinical picture was dominated by intermittent acute episodes followed by extended periods of recovery; in the last 2 years her disability became permanent with gradual deterioration. A likely diagnosis is multiple sclerosis of the relapsing-remitting type that subsequently developed into secondary progressive multiple sclerosis.

Jean-Martin Charcot was, in 1868, one of the first physicians to describe multiple sclerosis as a nosological entity. In the years that followed, clinical reports of the disease appeared, predominantly in Europe and North America, and Sir William Gowers in 1888 gave a comprehensive account of it, under the heading “Disseminated or Insular Sclerosis”, in his magisterial textbook (dubbed “the bible of neurology”). He acknowledged that identification of the condition had been recent. Constance's doctors of the 1890s might have been unaware of this newly defined diagnosis and, therefore, puzzled by her unusual symptomatology.

Constance Wilde, aged 38 years, photographed in Heidelberg in 1896 Copyright © 2015 Merlin Holland

By early 1898 Constance, restricted in her mobility, depleted of energy, and practically housebound, renewed her contact with Bossi. Another of her troublesome complaints was genitourinary dysfunction, attributed by Bossi to a uterine fibroid, which, he claimed, was also causing her leg weakness by compressing the nerves of her thigh. At first Bossi adopted conservative treatment by inserting a vaginal pessary and prescribing creosote lotion (an antiseptic) for application to the perineal area. When these measures proved ineffective, he recommended surgery. Desperate for a cure and persuaded that this would restore her walking, Constance consented despite the potential hazards of an operation.

It took place on April 2, 1898, and Bossi told Otho Holland, Constance's brother, in an interview after her death, that he did not attempt a hysterectomy but merely excised the tumour in a myomectomy. On the third or fourth postoperative day, Constance developed intractable vomiting. Profoundly dehydrated and in the absence of intravenous fluids, she grew progressively weaker, lapsed into unconsciousness, and died on April 7, 1898. This sequence of events suggests that she could have developed severe paralytic ileus, either as a direct result of the surgery or secondary to intra-abdominal sepsis.

Multiple sclerosis is associated with genitourinary symptoms in about two-thirds of female patients. It is conceivable, in Constance's case, that the apparent pressure effects on the bladder (supposedly due to a fibroid) were really a manifestation of multiple sclerosis. Similarly, we surmise that the surgery Bossi performed in December, 1895 was probably an anterior vaginal wall repair to correct urinary difficulties from a presumed bladder prolapse. In retrospect, the actual problem was probably neurogenic and not structural in origin.

Bossi had a distinguished national and international career in obstetrics and gynaecology. He became professor of gynaecology at Genoa University and was elected to a fellowship of the British Gynaecological Society. He published widely, including a well-received manual of obstetrics for midwives, and he introduced the Bossi dilator (long since obsolete) to effect rapid dilatation of the cervix in complicated labour. He was an active socialist and served as a deputy in the Italian legislature from 1900 to 1904. Bossi therefore enjoyed a considerable reputation in Italian society, both medically and politically.

But he presented another, more controversial side. Between 1850 and 1900 certain gynaecologists in North America and Europe maintained that lesions of the female reproductive system could induce insanity (“pelvic madness”) by reflex irritation of the brain, for which the remedy was removal of both ovaries. Bossi was not only an ardent advocate of this approach but championed it into the 20th century. He attempted to cure some patients with neurological and mental illness with gynaecological operations. He set out his position in two books: one on utero-ovarian disease and insanity (1912), the other on hysteria and gynaecology (1917). But his beliefs and practices aroused vehement opposition from some colleagues. In 1918, he was summoned before a disciplinary tribunal for unethical behaviour and professional misconduct, and suspended from his professorship for 2 years.

Otho Holland, in shock and grief at his sister's sudden death, contemplated litigation against Bossi but was dissuaded because Constance had willingly submitted to the operation, having been convinced by Bossi that surgery would relieve her disabilities and enable her to lead a normal life. Constance's London and Heidelberg doctors had warned her not to be coaxed into surgery, but she ignored their advice, confident that Bossi's treatment would rehabilitate her; instead it cost her her life. The final irony in this tragic saga was that on Feb 1, 1919, Bossi was shot dead in his consulting room in Milan by the jealous husband of a patient, who then fired at his wife before turning the gun on himself. Ultimately, both Bossi and the hapless Constance met their ends tragically: he by the bullet of an assassin and she by the knife of an irresponsible surgeon.

Much of the material in this essay has been extracted from private family papers in the possession of Merlin Holland.