Sydenham’s Practice in Smallpox.
Sydenham occupied his pen largely with smallpox, and gained much of his reputation by his treatment of it. At the root of his practice lay the distinction that he made between discrete smallpox and confluent. His practice in the discrete form was to do little or nothing, leaving the disease to get well of itself. Whether the eventual eruption were to be discrete or confluent, he could not of course tell for certain until two or three days after the patient sickened; but in no case was the sick person to be confined to bed until the eruption came out. If the latter were sparse or discrete, the patient was to get up for several hours every day while the disease ran its course, the physician having small occasion to interfere with its progress: “whoever labours under the distinct kind hardly needs the aid of a physician, but gets well of himself and by the strength of nature.” One may see how salutary a piece of good sense this was at the time, by taking such a case as that of John Evelyn, narrated by himself[832]. He fell ill at Geneva in 1646, and was bled, leeched and purged before the diagnosis of smallpox was made. “God knows,” he says, “what this would have produced if the spots had not appeared.” When the eruption did appear, it was only the discrete smallpox; the pimples, he says, were not many. But he was kept warm in bed for sixteen days, during which he was infinitely afflicted with heat and noisomeness, although the appearance of the eruption had eased him of his pains. For five whole weeks did he keep his chamber in this comparatively slight ailment. When he suggested to the physician that the letting of blood had been uncalled for, the latter excused the depletion on the ground that the blood was so burnt and vicious that the disease would have turned to plague or spotted fever had he proceeded by any other method[833].
As there were many such cases, Sydenham’s radical distinction between discrete and confluent smallpox, with his advice to leave the former to itself, was of great value, and is justly reckoned to his credit. But in the management of confluent smallpox he advised active interference. If there were the slightest indication that the disease was to be confluent (that is to say, the eruption copious and the pocks tending to run together), he at once ordered the patient to receive a vomit and a purge, and then to be bled, with a view to check the ebullition of the blood and mitigate the violence of the disease. Even infants and young children were to have their blood drawn in such an event. This heroic treatment at the outset was according to the rule of obsta principiis; by means of it he thought to divert the attack into a milder course. The initial depletion once over, Sydenham had resort to what is known as the cooling regimen. He set his face against the “sixteen days warm in bed,” which Evelyn had to endure even in a discrete smallpox. It was usually a mistake for the patient to take to bed continually before the sixth day from his sickening or the fourth day from the appearance of the eruption; after that stage, when all the pustules would be out, the regimen would differ in different confluent cases, and, of course, in some a continuance in bed would be inevitable as well as prudent. In like manner cardiac or cordial remedies, which were of a heating character, were indicated only by the patient’s lowness. The more powerful diaphoretic treacles, such as mithridate, were always a mistake. The tenth day was a critical time, and then paregoric was almost a specific. In the stage of recovery it was not rarely prudent to prescribe cordial medicines and canary wine. Thus, on a fair review of Sydenham’s ordinances for smallpox in a variety of circumstances, it will appear that he did not carry the cooling regimen to fanatical lengths and that he was sufficiently aware of the risks attending a chill in the course of the disease[834].
Apart from his rule of leaving cases of discrete smallpox to recover of themselves, Sydenham’s management of the disease was neither approved generally at the time, nor endorsed by posterity. His phlebotomies in confluent cases, usually at the outset, but sometimes even after the eruption was out if the patient had been under the heating regimen before, were an innovation borrowed from the French Galenists. The earlier writers had, for the most part, excepted smallpox among the acute maladies in which blood was to be drawn. But the Galenic rules of treatment were made more rigorous in proportion as they were challenged by the Paracelsist or chemical physicians, and it was among the upholders of tradition that blood-letting was extended to smallpox. Whitaker says that, when he was at St Germain with the exiled Stuarts, the French king was blooded in smallpox ten or eleven times, and recovered; “and upon this example they will ground a precept for universal practice.”
The ambiguity of the diagnosis at the outset, and the desire to lose no time, may have been the original grounds of this indiscriminate fashion of bleeding. Evelyn’s doctor at Geneva in 1646, “afterwards acknowledged that he should not have bled me had he suspected the smallpox, which brake out a day after,” but eventually he defended his practice as having made the attack milder. In like manner Sir Robert Sibbald, of Edinburgh, (1684) took four ounces of blood from a child of five, who was sickening for some malady; when it turned out to be smallpox, the mother expressed her alarm that blood should have been drawn; but Sibbald pointed to the favourable character of the eruption as justifying what he had done: “Optime enim eruperunt variolae, et ab earum eruptione febris remissit[835].”
The ill effects of blood-letting, says Whitaker, may be observed in French children, which by this frequent phlebotomizing are “withered in juvenile age.” Therefore, he concludes, blooding in smallpox should not be a common remedy, “but in such extremity as the person must lose some part of his substance to save the whole.” He calls it the rash and inconsiderate practice of modish persons; “and if the disease be conjunct [confluent], with an undeniable plethory of blood, which is the proper indication of phlebotomy, yet such bleeding ought to be by scarification [upon the arms, thighs or back] and cupping-glasses, without the cutting of any major vessel.” Another English physician of the time, Dr Slatholm, of Buntingford in Hertfordshire, who wrote in 1657[836], says that he had known physicians in Paris not to abstain from venesection in children of tender age, even in sucklings. He had never approved the letting of blood in such cases, lest nature be so weakened as to be unable to drive the peccant matter to the skin. For the most part, he says, an ill result follows venesection in smallpox; and although it sometimes succeeds, yet that is more by chance than by good management. As to exposing the sick in smallpox to cold air, he declares that he had known many in benign smallpox carried off thereby, instancing the case of his brother-in-law, the squire of Great Hornham, near Buntingford, whose death from smallpox in November, 1656, in the flower of his age, he set down to a chill brought on “ejus inobedientia et mulierum contumacia[837].”
The cooling regimen, as well as the danger of it, was familiar long before Sydenham’s time. There could be no better proof of this than a bit of dialogue in Beaumont and Fletcher’s ‘Fair Maid of the Inn’ (Act II. scene 2), a comedy which was licensed in January, 1626:
Host. And you have been in England? But they say ladies in England take a great deal of physic.... They say ladies there take physic for fashion.
Clown. Yes, sir, and many times die to keep fashion.
Host. How! Die to keep fashion?
Clown. Yes: I have known a lady sick of the smallpox, only to keep her face from pit-holes, take cold, strike them in again, kick up the heels, and vanish.
Sydenham says that the heating regimen was the practice of empirics and sciolists. Per contra his distinguished colleague Morton says that every old woman and apothecary practised the cooling regimen, and he points the moral of its evil consequences in a good many of his sixty-six clinical cases[838]. He pronounces the results of the cooling regimen to have been disastrous; he had been told that Sydenham himself relaxed the rigour of his treatment in his later years. There was so little smallpox for some fifteen years after the date of Morton’s book (1694) that the controversies on its treatment appear to have dropped. But, on the revival of epidemics in 1710 and 1714, essays were written against blooding, vomits and purges in smallpox[839].
In 1718, Dr Woodward, the Gresham professor of physic and an eminent geologist, published some remarks on “the new practice of purging” in smallpox, which were directed against Mead and Freind. In 1719 Freind addressed a Latin letter to Mead on the subject (the purging was in the secondary fever of confluent smallpox), and a lively controversy arose in which Freind referred to Woodward anonymously as a well-known empiric. On the 10th of June, 1719, about eight in the evening, Woodward was entering the quadrangle of Gresham College when he was set upon by Mead. Woodward drew his sword and rested the point of it until Mead drew his, which he was long in doing. The passes then began and the combatants advanced step by step until they were in the middle of the quadrangle. Woodward declared (in a letter to the Weekly Journal) that he was getting the best of it, when his foot slipped and he fell. He found Mead quickly standing over him demanding that he should beg his life. This Woodward declined to do, and the combat degenerated to a strife of tongues[840]. Next year the controversy over the treatment of smallpox assumed a triangular form. The third side was represented by Dr Dover, who had been something of a buccaneer on the Spanish main and was now in practice as a physician. An old pupil of Sydenham’s, he still adhered to blood-letting in smallpox; and in the spring of 1720, when the disease was exceedingly prevalent among persons of quality in London, he claimed to have rescued from death a lady whom Mead had given over, by pulling off the latter’s blisters and ordering a pint of blood to be drawn. “He hath observed the same method with like success with several persons of quality this week, and is as yet in very great vogue.... He declaims against his brethren of the faculty [especially Mead and Freind], with public and great vehemence, and particularly against purging and blistering in the distemper, which he affirms to be the death of thousands[841].”
Huxham, another Sydenhamian, appears to have practised not only blooding in smallpox, but also blistering, purging and salivating[842]. But in that generation the practice was exceptional; so much so that when it revived in some hands about 1752 (including Fothergill’s), it was thus referred to in a letter upon the general epidemic of smallpox in that year: “I have heard that bleeding is more commonly practised by some of the best physicians nowadays than it was formerly, even after the smallpox is come out[843].” In smallpox the lancet, like other methods, has been in fashion for a time, and then out of fashion; but the old teaching that smallpox did not call for blood-letting was ultimately restored. When Barker, in 1747, gave a discourse before the College of Physicians on the “Agreement betwixt Ancient and Modern Physicians,” he did not venture to defend Sydenham’s blooding in smallpox, although he would not admit that he was “a bloodthirsty man[844].”