“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.
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.”