What killed Charles II?

Sunday, June 17th, 2012 | Peter Anstey | No Comments

Terence Doyle writes…

Charles II, at the age of 54, laid down his earthly crown for an immortal one at noon on Friday February 6th 1685. His last illness is surely the best documented case history in the seventeenth century. There were multiple eyewitness accounts. The official version was penned by the Chief Royal Physician Sir Charles Scarburgh and later transcribed in The Last Days of Charles II by Raymond Crawfurd, (Clarendon Press, Oxford, 1909). It makes disturbing reading.

Charles was an apparently healthy man, reputed to have had thirteen mistresses and fifteen illegitimate children. On Monday morning, February 2nd 1685, while at his ablutions, he suffered a seizure with convulsions and temporary slurring of speech. Two physicians were on hand and one, Edmund King, withdrew 16 ounces of blood (450ml) from the king’s right arm, apparently with immediate relief. Six more physicians soon arrived and removed another 8 ounces with cupping glasses applied to deep scarifications in the shoulders. He was then given both an emetic and a purgative to empty his stomach and bowels. This was followed by two enemas and further purgatives. Then, according to the official account, Praeterea ut nullum lapidem immotum reliquerent (to leave no stone unturned) blistering agents were applied all over his head, after his hair had been shaved.

It was then decided to relieve the pressure of the humours on the brain by inducing sneezing, with a powder of white hellebore roots and later Sal Ammoniac applied to the nostrils. So as to keep his bowels active at night, more laxatives were given two hourly. At the same time, to counteract the scalding of his urine, from the Cantharides in the blistering drugs, a soothing emulsion of barley with liquorice was given. Et ne quid intentum relinqueretur (so as to leave nothing untried), plasters containing Spurge and Burgundy Pitch were applied to the soles of his feet.

On Tuesday he was bled ten ounces from the jugular veins. On Wednesday he was given further laxatives but that night he became so ill that his doctors prescribed Spirit of Human Skull (40 drops). This was commonly used in convulsive disorders and thought to act through the power of suggestion, since the skull had to be from someone who had died violently. On Thursday the King’s ministers were asking just what was wrong with him – a piece of intelligence the doctors themselves would have been happy to have. It was then suggested that he was suffering from intermittent fever and so was given syrup of Chinchona (Jesuit’s) bark three hourly, according to a prescription signed by 14 doctors.

On the morning of Friday 6th he was bled again and given an extract of a very large number of herbs, powdered oyster shells and Goa stone. This latter was a concretion (bezoar) formed in the stomach of an East Indian goat and was believed to have mystical ability to counteract poisons and strengthen the vital powers.  By mid-morning he was severely short of breath compelling him to sit upright. By ten he was comatose, and at noon he died.

On Saturday 7th an autopsy was performed, presumably because the illness was unexplained. The results of the autopsy are well documented.

 In Cerebri Cortice Venae et Arteriae supra modum repletae. (The veins and arteries on the brain surface were abnormally full).

Cerebri tum ventriculi omnes serosa quadam materia inundati, tum ipsa substantia consimili humore haud leviter imbuta. (The cerebral ventricles were filled with a kind of bloody material and the brain substance contained a similar humour).

The lungs were Sanguine referta (congested with blood). The heart and abdominal organs were unremarkable.

Crawfurd confidently sums this up with: ‘From these accounts one may assert with considerable confidence that his death was due to chronic granular kidney (a form of Bright’s disease) with uraemic convulsions, ‘He was a large eater and mainly of albuminous food. Alcohol he had taken freely, at times to gross excess: he had been the slave of sexual passion’ (p. 16).

This is manifestly incorrect. At autopsy the kidneys were normal and so Bright’s disease (chronic glomerulonephritis) is most unlikely. Overindulgence in eating, alcohol and sex, although lamentable, rarely results in death. The clinical history sounds like cerebral bleeding, probably subarachnoid. This is due to leakage from an arterial aneurysm, minor at first but irritating to the coverings of the brain. Charles remained conscious and there was no limb weakness. The first subarachnoid haemorrhage has an increased likelihood of a second more catastrophic bleed after a few days, this time into the brain substance. This pattern fits Charles’ clinical course. Just before he died he became severely short of breath. This is likely to have been caused by neurogenic pulmonary oedema, sometimes associated with intracerebral events. Finally, the autopsy findings state that the cerebral ventricles were filled with bloody fluid and a similar kind of material in the brain substance. This is just what would be expected in subarachnoid and secondary intracerebral bleeding.

Who performed the autopsy is not recorded. However, since Richard Lower had much the most experience of intracranial examination after working with Thomas Willis, he must have been involved.

Despite theoretical advances in medical science at this time, practical treatment as shown in the King’s management was still rooted in humoural theory. Towards the end of his illness Charles made his famous remark about being an unconscionable time a-dying, which sounds more like a prayer for deliverance than an apology.

 

Richard Lower’s De Catarrhis and Charles II’s last sneeze.

Monday, May 28th, 2012 | Peter Anstey | No Comments

Terry Doyle writes…

 

To the modern mind, one of the more surprising therapeutic manoeuvres inflicted on the Charles II as he lay dying of a cerebral disorder (more of that in another blog) in February 1685 was to make him sneeze. This was done by applying powder of white hellebore roots to his nostrils. He was also given Spirit of Sal Ammoniac tam ad invigorandum Cerebrum quam ad Sternutationem excitandum (both as a cerebral stimulant and to provoke sneezing). The ancient belief was that the animal spirits are produced and stored in the fluid of the cerebral ventricles. This was secreted through the pituitary, then dripped into the palate and also through the cribriform plate of the ethmoid bone into the nasal cavity. According to the medical theory of the time, sneezing would help to purge the brain of humours affecting it. What is interesting is whether or not one of the Royal Physicians, Richard Lower agreed to this.

Lower is best known for performing the first successful blood transfusion and for his Tractacus de Corde wherein he accurately described the structure of heart muscle. Later editions of this work contained a short additional chapter entitled Dissertatio de origine catarrhi.

Richard Lower

A reviewer noted that Lower demonstrated ‘the erroneousness of the Vulgar opinion . . . of those that apprehend great danger to the Brain from the excrementitious matter fathered therein, if it should not be purged out from thence by the Eyes, Nostrils, Ears and the Palat.’ (Philosophical Transactions 6 (1671) 2211-2). A facsimile reproduction of De Catarrhis was produced and edited by R. Hunter and I. Macalpine London, Dawsons, 1963.

Lower had extensive experience in brain research from his days in Oxford where he was the valued assistant to Thomas Willis in his production of Cerebri Anatome.

In the preface to the 1664 edition Willis wrote: ‘I made use of the Labours of the most Learned Physician and highly skilled Anatomist, Doctor Richard Lower, for my help and Companion . . . the edge of whose Knife and Wit I willingly acknowledge . . . as also his indefatigable Industry, and unwearied Labour.’ In the twelfth chapter of that work, Willis concluded that it was not possible for the cerebral fluid to be secreted into the palate. Among other things Lower investigated the ability of the arterial circle at the base of the brain, eponymously styled the Circle of Willis, to maintain the blood supply to the brain after three of the four feeding vessels had been tied off – as he described in his correspondence with Boyle (1744) The Works, London, Millar, vol. 5.

In De Catarrhis Lower demonstrated by injection of milk and ink that cerebral fluid could not pass from the brain, through the cribriform plate of the ethmoid bone into the nasal cavity and that nasal catarrh had nothing to do with the brain. He suggests that ‘almost everyone is agreed’ that the substance of catarrh consists of the serum of the blood and that it originates . . . by blocked perspiration through the pores of the body.’ Lower correctly suggests that the function of the moisture of nasal mucosa is to lubricate the inspired air. However, he mistakenly thought that the cerebral fluid passed directly from the pituitary into the bloodstream. He arrived at this conclusion by injecting milk into the internal jugular veins in the neck and noting that it bubbled out in two vessels on either side of the pituitary stalk. These are the cavernous sinuses which are next to but not in communication with the pituitary.

Yet despite Lower’s demonstration that catarrh had nothing to do with the brain, doctors continued to treat diseases of the head with errhines and sternutatories to encourage the flow of ‘pituita’ to clear the brain. Similarly, phlebotomy was a standard treatment long after humoural theory had been abandoned. Furthermore, liver disorders were treated with bleeding from the right arm and splenic disorders from the left arm. Charles II was bled from his jugular veins since his disorder was cerebral.

In all there were fifteen Royal Physicians, including Lower, attending Charles in his last illness. We know who they are as they signed the prescriptions given to the king as recorded in The Last Days of Charles II by Raymond Crawfurd, (Clarendon Press, Oxford, 1909), pp 56-68. They were all prominent London physicians and likely represented the best medical opinion of the day. Four are of particular interest.

The Chief Royal physician was Sir Charles Scarburgh, a founding member of the Royal Society, an accomplished mathematician and bibliophile. He had been a protégé of William Harvey, assisting him with De generatione animalium and attending him in his last illness.

Sir Thomas Millington 1625-1703, graduate of Westminster School (like, Lower, Wren, Hooke and Locke), friend of Hobbes and executor of Richard Lower’s will. Tractacus de Corde was dedicated to him by ‘Your most affectionate friend Richard Lower.’

Walter Charleton played a major part in introducing the ideas of Epicurus and Pierre Gassendi into England in his Physiologia Epicuro-Gassendo-Charletonia: or a fabrick of science natural, Upon the Hypothesis of Atoms (1654)

Sir Edmund King, like Lower, was a pupil of Thomas Willis in Oxford. In November 1667, he assisted Lower in performing the first human blood transfusion (on Arthur Coga who had agreed to this for a guinea). He later claimed to have dissected more than a hundred brains: Philosophical Transactions of the Royal Society 185 (Nov. – Dec., 1686), 231.

When each prescription was made out for the King, it was signed by 10 or 12 of the physicians. Most were for purgatives or bleeding. This raises the interesting research question – To what extent was humoural theory practised by physicians who decried it in their written work. Was this because they deferred to the patient’s expectations?