The Peruvian Bark Controversy.
It can hardly be doubted that the conflicting opinions as to the benefit of Peruvian bark in ague, which have been often cited in disparagement of medicine and as an example of its intolerance, arose from the indiscriminate use of it in “agues” diagnosed as such by quacks and pushing practitioners. The bark had been brought first to Spain in 1632 and had been tried medicinally in 1639[573]. It was under the powerful patronage of the Jesuits, especially of Cardinal de Lugo, and most of it at that time found its way to Rome, the centre of a malarious district. In 1652 it failed to cure a “double quartan” in an Austrian archduke, and thereafter fell into some disrepute. A violent controversy on its specific use in agues arose in the Netherlands; it had failed in every case at Brussels, it had not failed in a single case at Delft. Meanwhile it remained, very dear, sixty florins having been paid at Brussels in 1658 for as much as would make twenty doses, to be sent to Paris. The London ‘Mercurius Politicus’ of the week 9-16 December, 1658, contained an advertisement[574] that a supply of it had been brought over by James Thompson, merchant of Antwerp, and was to be had either at his own lodgings at the Black Spotted Eagle in the Old Bailey or at Mr John Crook’s, bookseller, at the sign of the Ship in St Paul’s Churchyard. The London physicians such as Prujean and Brady countenanced it, and Willis, in reprinting his essay on Fevers in 1660, spoke of it as coming into daily use. Sydenham, whose publisher was the same Crook at the sign of the Ship, made a brief reference to it in the first edition (1666) of his Observationes Medicae, in the section upon the epidemic constitution of intermittents during the years 1661-64. He admits that the bark could keep down fermentation for the time being; but the materies which the fermentation would have dissipated if it had been allowed its way, will remain in the system and quickly renew its power. He had known a quartan continue for several years under the use of bark. It had even killed some patients when given immediately before the paroxysm. Prudently and cautiously given, in the decline of such fevers, it had been sometimes useful and had stopped the paroxysms altogether, especially if the aguish fits were occurring at a season when the malady was less epidemical. But it is clear that Sydenham in 1666 inclined strongly to non-interference with the natural depuratory action of the fever upon the materies of the disease. His teaching that the cortex, while it kept down the fermentation of the blood for a time, left the dregs of the fever behind, was thus popularly stated some years after by Roger North in relating the fatal illness of his brother the Lord Keeper Guilford in the summer of 1685[575].
The fever of Lord Guilford was not an intermittent at all, but a “burning acute fever without any notable remissions and no intermissions,” a case of the epidemic typhus of that and the succeeding year, elsewhere described. The treatment was first in the hands of Dr Masters, pupil and successor of Dr Willis, whose cardinal doctrine of fevers was that they were a natural fermentation of the blood. He ordered phlebotomy. Next Dr Short, of another school, was sent for: “So to work with his cortex to take it off: and it was so done; but his lordship continued to have his headache and want of sleep. He gave him quieting potions, as they called them, which were opiates to make him sleep; but he ranted and renounced them as his greatest tormentors, saying ‘that they thought all was well if he did not kick off the clothes and his servant had his natural rest; but all that while he had axes and hammers and fireworks in his head, which he could not bear.’ All these were very bad signs; but yet he seemed to mend considerably; and no wonder, his fever being taken off by the cortex. And it is now found that, without there be an intermission of the fever, the cortex doth but ingraft the venom to shoot out again more perniciously.” The Lord Keeper’s illness dragged on, and at length the physicians “found he had a lent fever which was growing up out of the dregs which the cortex had left; and if it were not taken off, they knew he would soon perish. So they plied him with new doses of the same under the name of cordial powders, whereof the quantity he took is scarce credible; but they would not touch his fever any more than so much powder of port. And still he grew worse and worse. At length the doctors threw up[576].”
Sydenham having indicated in his edition of 1666 that bark was dangerous when given immediately before a paroxysm, but that it was sometimes useful in the decline of the fever, and that its benefits were greatest in those desultory agues which appeared at, or continued into, a season when agues had become less epidemical, he proceeded in his third edition of 1675 to enlarge these indications for giving bark in ague. He begins, as Talbor had begun in his essay of 1672, and as the empiric Streater had in his advertisement of 1641, by calling quartans the opprobrium medicorum, and he then lays down precisely how bark was to be given in those obstinate fevers, as well as in tertians of the aged or feeble: namely, after the fever had exhausted itself suo Marte, in the intervals between two paroxysms, an ounce of bark (in two ounces of syrup of roses) to be taken in the course of the two free days, a fourth part at a time morning and evening. The dosage may have been borrowed from Talbor, as Sir George Baker alleges[577]; it matters little for anyone’s fame. Sydenham, however, in a letter of October, 1677, thus claimed to have been independent of Talbor so far as concerned the directions for giving bark which he inserted in his edition of 1675:
“I have had but few trials, but I am sure that an ounce of bark, given between the two fits, cures; which the physicians in London not being pleased to take notice of in my book, or not believing me, have given an opportunity to a fellow that was but an apothecary’s man, to go away with all the practice on agues, by which he has gotten an estate in two months, and brought great reproach on the faculty[578].”
Talbor was patronised by Charles II., who caused him to be made one of his physicians. On 2 May, 1678, a few months after the date of Sydenham’s letter, Lord Arlington wrote to the president of the College of Physicians[579]: “His Majesty, having received great satisfaction in the abilities and success of Dr Talbor for the cure of agues, has caused him to be admitted and sworn one of his physicians.” Next year, 1679, the king had an attack of the reigning ague, and a recurrence of it in 1680. It is probably to the occasion of one or other of these attacks that an undated letter belongs from the Marquis of Worcester to the marchioness: “The physicians came to the Council to acquaint them that they intend to give the king the Jesuit’s powder five or six times before he goes to Newmarket, which they agreed to. He looks well, eats two meals of meat a day, as he used to do[580].” Evelyn has preserved a story told him by the Marquis of Normanby, which probably relates to the same aguish attack of Charles II.[581]:
“The physicians would not give the quinquina to the king, at a time when, in a dangerous ague, it was the only thing that could cure him (out of envy, because it had been brought into vogue by Mr Tudor [Talbor] an apothecary), till Dr Short, to whom the king sent to know his opinion of it privately, sent word to the king that it was the only thing which could save his life, and then the king enjoined his physicians to give it to him, which they did, and he recovered. Being asked by this lord [Normanby] why they would not prescribe it, Dr Lower said it would spoil their practice, or some such expression.”
What Dr Lower was most likely to have said was, that it went against his principles to give bark in fevers. He was a physiologist, in the sense of an anatomist, the pupil of Willis at Oxford and his successor in practice in London. It was the teaching of Willis that blood was like the juice of vegetables, particularly the juice of the grape, in respect of fermenting, just as it was like milk in respect of curdling. Fever was a sudden access of fermentation, apt to arise in spring and autumn, from internal or constitutional occasions, as well as to come at any time by infection; by this febrile ferment, ebullition or commotion, the blood was purged of certain impurities, comparable to the lees of wine, which were removed from the body in the sweat, the urine or other critical evacuation. Jesuit’s bark was believed to check fermentation, or, in the later phrase of Pringle and others, it was antiseptic; and it was probably because he thought it would check the natural defaecating action of the blood in an ague that Lower refused to prescribe it. Sydenham was more tentative, pliant, empirical. He cavilled at Willis’s doctrine of the ebullition or fermentation of the blood without actually rejecting it; for he held practically the same view of the salutary or depuratory nature of fever, which was indeed the Hippocratic view of it. Accordingly in his first reference to bark, in 1666, he sustains the objection to it, that it interfered with a natural depuratory action; and it was only in following the lead of Talbor, a more empirical person than himself, that Sydenham overcame his doctrinal scruples. Dr Short, to whom Charles II. sent privately for advice, was of Sydenham’s party; soon after that occasion, the latter dedicated to Short his ‘Tractate on Gout and Dropsy’ (1683). It was Short who “went to work with his cortex” upon the Lord Keeper in 1685, after Dr Masters, of the school of Willis, had tried his hand with phlebotomy. The king’s experiences, a few months before the Lord Keeper’s death, had been just the same, and with the same result: the deathbed of Charles II., it is well known, was the scene of ecclesiastical rivalries; but the physicians at the bedside of the king had their rivalries too.
On Monday the 2nd of February, at eight in the morning, the king had a seizure of some kind in his bed-chamber, which was currently said to have been an “apoplectic fit[582],” although there is nothing said of paralysis. A letter of the 3rd February[583] says the king “was seized in his chair and bed-chamber with a surprising convulsion fit which lasted three hours.” Dr King, an expert operator who had assisted Lower in the delicate operation before the Royal Society on 23 November, 1667, of transfusing blood from one body to another, happened to be at hand, and, at once drawing his lancet, bled the king. His promptitude in action, which probably left him little time for diagnosis, was much applauded, and the Privy Council voted him a reward of a thousand pounds, which Burnet says he never received.
“This rescued his Majesty for the instant,” says Evelyn, (who came up from Wooton on hearing the news, and is probably correct in his narrative), “but it was only a short reprieve. He still complained, and was relapsing, often fainting, with sometimes epileptic symptoms, till Wednesday, for which he was cupp’d, let blood in both jugulars, had both vomit and purges, which so reliev’d him that on Thursday hopes of recovery were signified in the public Gazette; but that day, about noone, the physitians thought him feverish. This they seem’d glad of, as being more easily allay’d and methodically dealt with than his former fits; so as they prescribed the famous Jesuit’s powder: but it made him worse, and some very able doctors who were present did not think it a fever, but the effect of his frequent bleeding and other sharp operations us’d by them about his head, so that probably the powder might stop the circulation, and renew his former fits, which now made him very weake. Thus he pass’d Thursday night with greate difficulty, when, complaining of a paine in his side, they drew 12 ounces more of blood from him; this was by 6 in the morning on Friday, and it gave him reliefe; but it did not continue, for being now in much paine, and struggling for breath, he lay dozing, and after some conflicts, the physitians despairing of him, he gave up the ghost at halfe an houre after eleven in the morning, being 6 Feb. 1685, in the 36th yeare of his reigne, and 54th of his age.... Thus died King Charles II. of a vigorous and robust constitution, and in all appearance promising a long life[584].”
Whether the bark would have saved him if the aguish nature of the paroxysms (such as he had in 1679 and again in 1680) had been clear from the first, may be doubted. But his chances of recovery were certainly made worse by the halting and stumbling diagnosis, (according to Evelyn)—now apoplexy, now epilepsy, now fever[585].
The true value of cinchona bark in medicine was not seen until much that was vague in the use of the term “ague” had been swept away. In the last great epidemic period of agues in this country, as we shall see, from 1780 to 1786, bark was found, for some reason, to be ineffective. It is not in the treatment of epidemic agues, but of agues in malarious countries, that the benefits of Jesuits’ bark have been from first to last most obvious.
The practice in so-called agues was long in the hands of empirics, who, like their class in general, made business out of ignorant or lax diagnosis. I shall add here what remains to be said of specialist ague-curers in later times. They are heard of in London in the Queen Anne period, and as late as 1745.
Swift writes in his Journal to Stella, 25 December, 1710, from Bury Street, St James’s: “I tell you a good pun: a fellow hard by pretends to cure agues, and has set out a sign, and spells it egoes; a gentleman and I observing it, he said, ‘How does that fellow pretend to cure agues?’ I said, I did not know, but I was sure it was not by a spell. That is admirable.” In 1745, Simon Mason, of Cambridge, published by subscription and dedicated to Dr Mead an essay, The Nature of an Intermitting Fever and Ague considered (Lond. 1745), in which he has the following on “charm-doctors”:—“When one of these poor wretches apply to a doctor of this stamp, he enquires how many fits they have had; he then chalks so many strokes upon a heater as they tell him they have had fits, and useth some other delusions to strengthen the conceit of the patient” (p. 167). Francis Fisher, who had been upper hostler in a livery stable in Crutched Friars near forty years, “told me he seldom missed a week without several ague patients applying to him, and he cured great numbers by a charm they wore in their bosoms” (p. 239). Another, who kept a public-house near St George’s Fields, Southwark, sold “febrifuge ale” at a shilling a pint. It was a small ale brewed without hops, but with bark, serpentery, rhubarb and cochineal mixed in the brewing. The receipt was given him by an old doctor who was a prisoner in the King’s Bench. His customers came in the morning fasting, and drank their shilling’s worth after the publican had given them faith by a cordial grip of the hand. “By this means,” he told Mason, “I got a good trade to my house, and a comfortable maintenance too.”
We may now return to the actual history of the epidemic fevers upon which the Peruvian bark was first tried on a large scale in England. The “intermittent” constitution which began in 1677 and lasted year after year until 1781 or even longer was a very remarkable one. It was called at the time the new fever, or the new ague, and it had at least one short interlude of influenza or epidemic catarrhal fever in the winter of 1679, just as the last epidemic of the kind, in 1657-59, had at least one, and probably two, short and swift epidemic catarrhs in spring. But before we come to that epidemic of 1678-81, there falls to be noticed an epidemic in the month of November, 1675, which has always been counted among the influenzas proper. After giving the particulars of it from Sydenham and from the London bills of mortality, I shall show from Sydenham and the bills of mortality that there was an exactly similar epidemic in the month of November, 1679, which has not been admitted into the conventional list of influenzas. Thereafter I shall proceed to the epidemic constitution of 1678-81 as a whole, which has been reckoned among the epidemic agues or malarious epidemics.