Smallpox after the Restoration.
The period which must now concern us particularly, from the Restoration onwards, opens with two deaths from smallpox in the royal family within a few months of the return of the Stuarts. When Charles II. left the Hague on 23 May, 1660, to assume the English crown, his two brothers, the Duke of York and the Duke of Gloucester, accompanied him in the fleet. In the first days of September, the Duke of Gloucester was seized at Whitehall with an illness of which various accounts are given in letters of the time[818]. On 4 September, “the duke hath been very sick, and ’tis thought he will have the smallpox.” On the 8th “the doctors say it is a disease between the smallpox and the measles; he is now past danger of death for this bout, as the doctors say”; or, by another account, “the smallpox come out full and kindly, and ’tis thought the worst is past.” On the 11th the duke is “in good condition for one that has the smallpox.” But a day or two afterwards his symptoms took an unfavourable turn; the doctors left him, apparently with a good prognosis, one evening at six o’clock, but shortly after he bled at the nose three or four ounces, then fell asleep, and on awaking passed into an unconscious state, in which he died. When his body was opened, the lungs were full of blood, “besides three or four pints that lay about them, and much blood in his head, which took away his sense.” Pepys says his death was put down to the great negligence of the doctors; and if we can trust a news-letter of the time, their negligence was such as would have been now approved, for “the physicians never gave him anything from first to last, so well was he in appearance to everyone[819].” Three days after his funeral, the king and the Duke of York went to Margate to meet their sister, the princess Mary of Orange, on her arrival from the Hague. Her visit to the Court extended into the winter, and about the middle of December she also took smallpox, of which she died on the 21st. Pepys, dining with Lady Sandwich, heard that “much fault was laid upon Dr Frazer and the rest of the doctors for the death of the princess.” Her sister, the princess Henrietta, who had come on a visit to Whitehall with the Queen-mother in October, was removed to St James’s on 21st December, “for fear of the smallpox”; but she must have been already sickening, for on the 16th January it is reported that she “is recovered of the measles.”
These deaths at Whitehall of a brother and sister of Charles II. happened in the autumn and winter of 1660; but it was not until next year that the smallpox rose to epidemic height in London, the deaths from it having been only 354 in 1660, rising to 1246 in 1661, and 768 in 1662. In 1661 it appears to have been epidemic in other parts of England: Willis, who was then at Oxford, says that smallpox began to rage severely before the summer solstice (adding that it was “a distemper rarely epidemical”), and there are letters from a squire’s wife in Rutlandshire to her husband in London, which speak of the disease raging in their village in May and June[820].
There was much fever of a fatal type in London in 1661, which is more noticed than smallpox itself in the diary of Pepys. The town was in a very unhealthy state; and it would have been in accordance with all later experience if the “pestilential constitution” of fevers, which continued more or less until the plague burst forth in 1665, had been accompanied by much fatal smallpox. The occasion was used by two medical writers to remark upon the fatality of smallpox as something new. The second of the two essays (1663), was anonymous, and bore the significant title of Hactenus Inaudita, the hitherto unheard of thing being that smallpox should prove so fatal as it had been lately. The author adopts the dictum of Mercurialis, with which, he says, most men agree: “Smallpox and measles are wont for the most part to terminate favourably”; and he makes it clear in the following passage that the blame of recent fatalities was laid, justly or unjustly, at the door of the doctors, as, indeed, we know that it was from the gossip of Pepys:
“And I know not by what fate physicians of late have more lost their credit in these diseases than ever: witness the severe judgment of the world in the cases of the Duke of Gloucester and the Princess Royal: so that now they stick not to say, with your Agrippa, that at least in these a physician is more dangerous than the malady[821].”
The other essay was by one of the king’s physicians, Dr Tobias Whitaker, who had attended the Court in its exile at St Germain and the Hague. He was by no means an empiric, as some were whom Charles II. delighted to honour; and, although he protests warmly against the modish injudicious treatment of smallpox by blooding and cooling, he has little of the recriminating manner of the time, which Sydenham used from the one side and Morton from the other. He is, indeed, all for moderation: “upon this hinge of moderation turneth the safety of every person affected with this disease.” His moderation is somewhat like that of Sir Thomas Browne (whose colleague he may have been for a few years at Norwich), and is apt to run into paradox. In 1634 he wrote in praise of water, including the waters of spas and of the sea, and in 1638 he wrote with even greater enthusiasm in praise of wine[822]. He says of his “most learned predecessor” at Court, Harvey, that his demonstration of the circular motion of the blood was a farther extension of what none were ignorant of “though not expert in dissection of living bodies.” On his return to London in 1660, he seemed to find as great a change in smallpox as in the disposition of the people towards the monarchy. His statement as to the change for the worse that had come over smallpox within his memory would be of the highest historical importance if we could be sure it was not illusory; it is difficult to reconcile with the London experiences of smallpox in 1628 and 1641, but, such as it is, we must take note of it:
“It is not as yet a complete year since my landing with his Majesty in England, and in this short time have observed as strange a difference in this subject of my present discourse as in the variety of opinions and dispositions of this nation, with whom I have discoursed.” This disease of smallpox, he proceeds, “was antiently and generally in the common place of petit and puerile, and the cure of no moment.... But from what present constitution of the ayre this childish disease hath received such pestilential tinctures I know not; yet I am sure that this disease, which for hundreds of yeares and before the practice of medicine was so exquisite, hath been as commonly cured as it hapned, therefore in this age not incurable, as upon my own practice I can testifie.... Riverius will not have one of one thousand of humane principles to escape it, yet in my conjecture there is not one of one thousand in the universe that hath any knowledge or sense of it, from their first ingress into the world to their last egress out of this world; which could not be, if it were so inherent or concomitant with maternal bloud and seed,” referring to the old Arabian doctrine, which Willis adhered to, that every child was tainted in the womb with the retained impure menstrual blood of the mother, and that smallpox (or measles) was the natural and regular purification therefrom. “But smallpox,” he continues, “is dedicated to infants more particularly which are moist, and some more than others abounding with vitious humours drawn from maternal extravagancy and corrupt dyet in the time of their gestation; and by this aptitude are well disposed to receive infection of the ayre upon the least infection[823].”
When Whitaker calls smallpox a “childish disease,” a disease that was “antiently and generally in the common place of petit and puerile, and the cure of no moment,” he says no more than Willis and others say of smallpox as it affected infants and children. Says Willis: “there is less danger if it should happen in the age of childhood or infancy”; and again: “the sooner that anyone hath this disease, the more secure they are, wherefore children most often escape”; and again: “the measles are so much akin to the smallpox that with most authors they have not deserved to be handled apart from them,” although he recognizes that measles is sooner ended and with less danger. Nor was Willis singular among seventeenth-century physicians in his view—“the sooner that anyone hath this disease the more secure they are.” Morton in two passages remarks upon the greater mildness of smallpox in “infants”: “For that they are less anxious about the result, infants feel its destructive force more rarely than others”; and again: “Hence doubtless infants, being of course ἀπαθεῖς, are afflicted more rarely than adults with the severe kinds of confluent and malignant smallpox[824].”
In the very first treatise written by an English physician specially on the Acute Diseases of Infants, the work by Dr Walter Harris, there is a statement concerning the mildness of “smallpox and measles in infants” (who are defined as under four years of age), which goes even farther than Morton’s:
“The smallpox and measles of infants, being for the most part a mild and tranquil effervescence of the blood, are wont to have often no bad character, where neither the helping hands of physicians are called in nor the abounding skill of complacent nurses is put in requisition[825].”
It has to be said, however, that Morton’s statement about infants is made to illustrate a favourite notion of his that apprehension as to the result, which infants were not subject to, made smallpox worse; and that Harris’s assertion of the natural mildness of the “smallpox and measles” of infants comes in to illustrate the evil done by the heating regimen of physicians and nurses, who are mentioned in obviously sarcastic terms. So also Sydenham says that “many thousands” of infants had perished in the smallpox through the ill-timed endeavours of imprudent women to check the diarrhoea which was a complication of the malady, but was in Sydenham’s view, although not in Morton’s, at the same time a wholesome relieving incident therein. If we may take it that infants and young children had smallpox in a mild form, or more rarely confluent than in adults, we may also conclude that many of them died, whether from the alexipharmac remedies which Morton advised and Sydenham (with his follower Harris) denounced, or from the attendant diarrhoea which Sydenham thought a natural relief to the disease and Morton thought a dangerous complication.
Making every allowance for motive or recrimination in the statements, from their several points of view, by Willis, Sydenham, Morton, Harris (Martin Lister might have been added), as to the naturally mild course of smallpox in infants, or when not interfered with by erroneous treatment, it cannot but appear that infantile smallpox at that time was more like measles in its severity or fatality than the infantile smallpox of later times. It is perhaps of little moment that Jurin should have repeated in 1723 the statements of Willis and others (“the hazard of dying of smallpox increases after the birth, as the child advances in age”)[826], for he had little intimate knowledge of epidemics, being at that time mainly occupied with mathematics, and with smallpox from the arithmetical side only. But it is not so easy to understand why Heberden should have said the same a generation after[827]; or how much credit should attach to the remark of “an eminent physician from Ireland,” who wrote to Dr Andrew, of Exeter, in 1765: “Infants usually have the natural pock of as benign a kind as the artificial[828].”
Whatever may have been its fatality or severity among infants and children, it was chiefly as a disease of the higher ages that smallpox in the Stuart period attracted so much notice and excited so much alarm. The cases mentioned in letters and diaries are nearly all of adults; and these were the cases, whatever proportion they may have made of the smallpox at all ages, that gave the disease its ill repute. About the middle of the 18th century we begin to have exact figures of the ages at which deaths from smallpox occurred: the deaths are then nearly all of infants, so much so that in a total of 1622, made up from exact returns, only 7 were above the age of ten, and only 92 between five and ten; while an age-incidence nearly the same continued to be the rule until after the great epidemic of 1837-39, when it began gradually to move higher[829]. But we should err in imagining that state of things the rule for the 17th century, just as we should err in carrying it forward into our own time. Not only are we told that smallpox of infants was like measles in that the cure was of no moment (which is strange), but we do know from references to smallpox in the familiar writings of the Stuart period that many of its attacks, with a high ratio of fatalities, must have happened to adults. Thus, to take the diary of John Evelyn, he himself had smallpox abroad when he was a young man, his two daughters died of it in early womanhood within a few months of each other, and a suitor for the hand of one of them died of it about the same time. Medical writings leave the same impression of smallpox attacking many after the age of childhood. Willis gives four cases, all of adults. Morton gives sixty-six clinical cases of smallpox, the earliest record of the kind, and one that might pass as modern: twelve of the cases are under six years of age, nine are at ages from seven to twelve, eleven from thirteen years to twenty, seven from twenty-two to forty, and all but two of the remaining twenty-four clearly indicated in the text, in one way or another, as adolescents or adults, the result being that 23 cases are under twelve and 43 cases over twelve[830].
That ratio of adults to children may have been exceptional. Morton was less likely to be called to infants than to older persons, even among the middle class; and no physician in London at that time knew what was passing among the poorer classes, except from the bills of mortality. But if Morton had practised in London two or three generations later, say in the time of Lettsom, when “most born in London have smallpox before they are seven,” his casebook would not have shown a proportion of forty-three cases over twelve years to twenty-three under that age. Whatever things contributed to the growing evil repute of smallpox among epidemic maladies, there is so much concurrent testimony to the fact itself that we can hardly take it to have been wholly illusion. In some parts the mildness of smallpox was still asserted as if due to local advantages. Thus Dr Plot, who succeeded Willis in his chair of physics at Oxford, wrote in 1677: “Generally here they are so favourable and kind that, be the nurse but tolerably good, the patient seldom miscarries[831].”
The reason commonly assigned for the large number of fatalities in smallpox after the Restoration was erroneous treatment. That is the charge made, not only in the gossip of the town, as Pepys reported it, but in Sydenham’s animadversions on the heating regimen, in Morton’s on the cooling regimen, and in the sarcasms of both physicians upon the practice of “mulierculae” or nurses. One may easily make too much of this view of the matter; it is certain that the incidence of smallpox, its fatality and its frequency in general, were determined in the Stuart period, as at other times, by many things besides. Still, the treatment of smallpox has always had the first place in its epidemiological history. The fashion of it that concerns us at this stage was the famous cooling regimen, commonly joined with the name of Sydenham.