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].”