medicine and mortality in the sixteenth century

It is fitting that the completion of the present collaborative study of health, medicine and mortality in the sixteenth century should coincide with the four hundredth anniversary of the birth of the physician William Harvey, and the three hundred and fiftieth anniversary of the publication of his De mots. cordis. 

The important subject of the life and work of William Harvey stands out as one of the few areas in the history of medicine to have been subjected to intensive historical scrutiny. In the present context it is interesting to note that Harvey was the subject of one of Sir William Osler's best-known lectures, 'The Growth of Truth as Illustrated by the Discovery of the Circulation of the Blood'.' In this Harveian Oration, as in his equally distinguished lectures on Sir Thomas Browne (19o5) and Thomas Linacre (1908), Osler convincingly argued for the study of medical history as a contribution to medical humanism. He believed that biographical studies of the great medical thinkers of the past would contribute to a definitive 'biography of the mind of man'. Such a programme, calling for the integrated application of the skills of the humanities and the sciences, was seen as an essential constituent of a medical humanism continuing into the present age of scientific medicine. Sanford Vincent Larkey, like Osler, was connected with the Johns Hopkins Medical School. Among its many innovations, Osler's medical school established one of the first university institutes for the history of medicine in the English-speaking world. Larkey was associated with this institute from its creation. He inherited Osler's conviction that the creation of collections of historical sources, and the compilation of professionally competent bibliographies, were essential pre-requisites for the development of the history of medicine. Larkey also shared Osler's commitment to the value of medical humanism. However, 

Lackey's conception of humanism differed significantly from that of Osier. Larkey's writings contain relatively little reference to such major figures as Harvey. Indeed his massive collection of bibliographical notes bypasses almost completely the names which are regarded as those of the founders of modern scientific medicine. Larkey subtly changed the emphasis of medical humanism, in accordance with what he regarded as the intellectual needs of the medical profession and the public, during a period of rapid advance in medical science coinciding with the upheavals caused by the Second World War. In the context of the ever-widening horizons of modem medicine, Larkey believed that it was essential to subject the medical system to historical analysis. His programme for medical humanism entailed the maintenance of a close relationship between medicine, history and the social sciences. By this means elements of arbitrary selectivity and distortion would be removed, and through 'greater co-ordination between the history of medicine and political, social and economic history, we would come to an 'examination of the past in the light of its own intellectual and social milieu'! As the quotation aptly cited at the head of the paper by Thomas Forbes in this volume indicates, Larkey's views were shared by Henry Sigerist, the Director of the Johns Hopkins Institute, who drew attention to the limitations of a history of medicine restricted entirely to the 'history of great doctors and the books they wrote'. Sigerist, himself author of Grosse Aare (1932), called for 'social history' of medicine, which would be concerned with 'the history of the patient in society, that of the physician and the history of the relations between physician and patient .s In elevating the patient to an integral place in the history of medicine, Larkey and Sigerist underlined the degree to which patients provide a necessary pre-requisite for the existence of medicine. Sanford Larkey was as faithful as any of his distinguished colleagues at Johns Hopkins in following the maxims of the social history of medicine. To be consistent, this new approach demanded a much finer degree of specialization than was traditionally to the liking of medical historians. Larkey opted for the study of medicine in Tudor England. This subject recommended itself by the obvious freshness and vitality of English post-reformation culture. This period was also characterized by 

the richness of its vernacular medical literature. Of the areas of enquiry not susceptible to organization in terms of the exegesis of great works, or major scientific innovations, none could be more conspicuously deserving of study than Tudor medicine. In exploring this area, Larkey found ready allies and collaborators in such scholars as F. R. Johnson, whose interest in medicine was awakened by an appreciation of the relevance of popular science to the understanding of Tudor literature. Universal fascination with all aspects of the 'Age of Shakespeare' guaranteed Larkey a receptive audience for his work. Despite its intrinsic attractions, however, Tudor medicine turned out to be a subject bristling with technical difficulties. The vernacular literature upon which Larkey worked included a large number of editions of the greatest rarity, presenting problems of bibliographical variation, authorship, and provenance of texts. But Larkey recognized that any balanced interpretation of Tudor medicine necessitated a great deal of painstaking and relatively unglamorous bibliographical work across the entire field of this literature. It was also clear that the faithful reconstruction of Tudor medicine required a diligent search into a much wider body of writing relating to other aspects of the sciences, and to subjects such as witchcraft and religion. I personally came fully to appreciate the high quality of Larkey's bibliographical work when asked to undertake the updating of his 1941 contribution on science, medicine, and related subjects included in volume t of the Cambridge Bibliography of English Literature. This selective but extensive bibliography displayed excellent judgment and great accuracy over its whole range, with respect to both primary and secondary sources. It became established as the definitive guide to the scientific and medical sources which were likely to have been utilized by contemporary literary figures. Because of Larkey's diligence, revision proved to be a straightforward exercise. The full scope of Larkey's work is described in detail in the essay and bibliography compiled by Margaret Felling for the present volume. As she indicates, Larkey's research publications significantly added to the range and accuracy of our knowledge of Tudor medicine. His work included some notable discoveries relating to the English influence of Copernicus, Vesalius and Columbo. But in the main Larkey was concerned to increase our knowledge of aspects of medicine which were of primary interest to contemporaries, hence his conclusive researches on the bibliographical maze surrounding the first English Herbal, and his edition of an early ophthalmological treatise. He brought into focus a whole spectrum of minor figures such as Geminus, Udall, Surphlet and 

Hunton, as well as adding to our awareness of major vernacular writers like Banister and Clowes. Throughout his career Lackey continued to amass materials in connection with various projects relating to Tudor medicine. His exhaustive collection of bibliographical notes now deposited in Pembroke College, Oxford. contains data essential for any definitive study of this subject. Regrettably, Larkey's many other scholarly, medical and public service commitments precluded him from bringing his project on Tudor medicine to final fruition. Nevertheless his published writings stand as an invaluable asset and a constant source of reference for present-day students of Tudor medicine. The Master and Fellows of Pembroke College decided that it would be appropriate to commemorate Sanford Larkey by sponsoring a collaborative volume on Tudor medicine, containing studies on themes with which Larkey was concerned, and adopting a scope which was consistent with his ideas on the social history of medicine. The direction taken by current research thoroughly vindicates Larkey's judgment as to profitable areas of research in the history of medicine. Subjects upon which he wrote many years ago, such as childbirth, or astrology and politics, now attract a keen following. Almost every subject discussed in this volume finds a point of reference in Larkey's published work or in his unpublished notes. It was felt that besides offering an opportunity for comment on health, disease and medicine from various vantage points within the social sciences, the present project would provide an ideal pretext for a collaboration between specialists whose work is too rarely gathered into a single volume. The full exploration of the resources of the history of medicine is only made practicable by exploiting the skills of authors whose contributions are normally dispersed through journals concerned with social history, economic history, demography, epidemiology, the various branches of medicine, as well as the history of science and medicine. It is a reflection of the high level of activity and enthusiasm among students of the topics covered in this volume that little difficulty was encountered in persuading colleagues to participate in the project. We are also fortunate in having been offered contributions which in the main reflect the results of very recent and hitherto unpublished researches. The boundaries of the various studies have not been rigidly defined. The sixteenth century provides a focal point, but on many occasions it has been found essential to draw comparisons with late medieval contexts, and more especially to carry over the investigation into the 

early Stuart period. In order to attain an adequate depth of detailed analysis, and to provide a sense of unity and continuity, most of the text is concerned with England. However, besides collectively providing a model appropriate for comparison with other localized surveys, most of these English case studies have involved cross-reference to the continental situation. In the case of essays based on literary sources, or relating to intellectual traditions, questions of continental influence acquire central importance. The significance of continental precedent is emphasized by the paper ofJerome Bylebyl on the highly cosmopolitan medical school of Padua. The present volume makes no claim to deal with every aspect of health, disease and medicine in sixteenth-century England. Such an attempt at comprehensive coverage would have led to an unacceptable degree of diffuseness in a volume of the present permitted length. Consequently we have preferred to include detailed investigations on important issues spanning the whole range of the subject. While scholars such as Larkey pioneered the study of the vernacular literature, recent research has led to the exploitation of even less accessible sources. Contributions in the present volume are hence heavily reliant on unpublished material such as parish records, wills, probate inventories, personal papers and institutional records. The use of such sources has permitted a much greater degree of quantification on the many issues which can only be effectively resolved in quantitative terms. This facet of our work has greatly benefited from data gathered under the aegis of the Cambridge Group for the History of Population and Social Structure. The volume divides fairly evenly into two major sections, the first concerned primarily with prevailing levels of health, and problems of disease, the second with agencies of health care. The contributions of Andrew Appleby and Paul Slack deal with the assessment of the changing pattern of health, with particular reference to the impact of epidemics and dearth. Their work enables us to establish more precisely the extent to which England was affected by crises of health and subsistence in the sixteenth century. Roger Schofield and E. A. Wrigley discuss the problem of mortality with respect to age-specific mortality rates, concentrating on infants and children as the most vulnerable age groups. Each of these early age groups is found to possess its characteristic mortality profile, amenable to explanation in terms of the changing balance of endogenous and exogenous factors. For the early modern period direct information defining causes of death is rarely 

Visitations of pestilence of one kind or another were familiar. inescapable features of the environment in Tudor England, regular reminders of the insecurity of life and the imminence of death. They produced years of exceptionally high mortality, when death rates in villages and towns doubled or trebled and the normal life of local communities was totally and tragically disrupted. Although these crises were of short duration, rarely lasting more than a year, and demographic and economic recovery was often rapid afterwards, they were memorable events, important landmarks in the annals of local societies. Their effects were recorded in diaries and chronicles, and each success-ive 'great plague' or 'great pestilence' was used as a natural point of reference until its place was usurped by the next epidemic year.' These crises were the spectacular features of the social and demographic, as well as the medical, landscape of early modem England. One purpose of this essay is to ask how frequent and how serious these years of high mortality were. That they were a characteristic part of the demographic structure of pre-industrial western Europe is well known. A recent analysis of their decline by M. W. Flinn indicates that the 'stabilisation of mortality' largely occurred in the eighteenth century. Sudden and large increases in mortality were much more common in the first three quarters of the seventeenth century than later, and Flinn suggests that mortality may well have fluctuated even more violently in the sixteenth than in the seventeenth century The examples which follow provide confirmation for this suggestion as far as England is concerned. Unfortunately, it has not been possible to present quantitative data precisely comparable with those given by Professor 

Flinn, since the sources for the earlier period are less complete and more variable in quality. In particular, it has been necessary here to adopt a slightly different definition of crisis. Professor Flinn has taken a $o per cent excess of mortality over and above the normal as a minimum requirement for a crisis in a single parish or town; but in this survey most cases in which mortality rose by less than too per cent in a single year have been excluded, in order to avoid doubtful cases and to reduce the size of the subject. Even so, the number of occasions on which mortality rates doubled in individual towns and villages is very large, a strong indication that the instability of mortality behaviour was at least as great in the sixteenth as in the seventeenth century. A second purpose of this paper is to enquire into the causes of these crises. The epidemic diseases, the plagues and pestilences which produced them, seemed to contemporaries unpredictable strokes of fate. They did not think them unrelated to other features of the environment. For they were one symptom of disorder in the universe, and as such they were inevitably connected with other disorders. They might be a consequence of astrological disturbance or political division, of war or famine, of bad hygiene or personal excess. But their timing and incidence were determined by divine providence and their first cause was supernatural: epidemics were God's punishment for man's sin. While abandoning supernatural interpretations, historians have continued to look for connections between mortality crises and other changes in the environment. They have sought to relate them above all to the state of the harvest, to problems of subsistence and the pressure of population on food supplies. However, while some increases in mortality undoubtedly did coincide with periods of near-famine, many more did not, and the relative importance of diseases associated with malnutrition is not yet established. Consequently, although many historians have adopted a neo-Malthusian approach to fluctuations in mortality, others have seen major epidemics as essentially exogenous, if not completely fortuitous, events. Professor Chambers, for example, has been able to stress with some force that epidemic disease was a largely 'autonomous influence on mortality in pre-industrial England.' Perhaps the most urgent, and certainly the most difficult task for the historian of crisis mortality is to analyse these interactions between 

disease and other features of society. Was pestilence as capricious and independent a stroke of fortune in past societies as it seemed ? It will quickly become apparent that there are no simple or certain answers to these problems. The forms taken by mortality crises are perplexing in their variety, and exceptions can readily be found to almost any generalization. The student of past epidemics needs no instruction in the manifold variations which occur in the relationship between biological and social change, and the study of particular instances needs to be advanced much further before there can be any approach to a satisfactory study of historical epidemiology. The aim of this essay is therefore to raise some of the questions which have emerged from work so far completed, and to suggest patterns and hypotheses which may help to stimulate further enquiry. 

Not the least of the historian's problems arise from the unevenness of the source materials for mortality in the sixteenth century, and these demand some initial consideration. There are two relevant sorts of record: parish registers and wills. The virtues and vices of parish registers are already well known, and it is unnecessary to describe them at length here.' The parochial registration of burials, along with baptisms and marriages, was first ordered in t 538. But registers do not survive in any large number before the reign of Elizabeth, and many Elizabethan registers are parchment copies made at the very end of the reign, which may or may not be accurate transcripts of paper originals. Even the best-kept registers are not complete records of mortality. They record burials in the churchyard, not deaths in the parish, and they arc subject to the errors and inefficiency of the parish clerks who compiled them. They are particularly liable to understate the number of deaths during a mortality crisis and sometimes in these circumstances registration broke down altogether. Parish registers are also limited by the small areas which they cover. It requires considerable effort to reconstruct from them a picture of mortality trends over a whole region. Nevertheless, these limitations have corresponding advantages. The problem of under-registration means that registers are unlikely to exaggerate the severity of the crises analysed here, and we shall see that their local coverage makes them excellent sources for measuring variations in the incidence of high 

mortality over small areas, particularly within large towns. With all their faults parish registers are indispensable. For the period before 1538 and for many areas of the country before 156o, we have to turn to a more questionable source: testamentary records. The number of wills proved from year to year in the various ecclesiastical courts ought in theory to reflect changes in the level of mortality in the dioceses or archdeaconries covered by them. Probate records, unlike parish registers, should thus provide a guide to fluctuations in mortality over large areas of the country. They have been used for this purpose in a study of the great epidemic of 1557-9 by F. J. Fisher, who argues that a large rise in the number of wills proved, followed by a similar or larger fall, 'is as good a measure of an epidemic as one is likely to fincl'.$ It is in fact the only readily available indicator of changes in mortality before the advent of parish registers.' Yet one needs to be cautious in drawing firm conclusions from these sources since they have major limitations. Not everyone made a will, and the proportion that did was not constant. Changes in testamentary habits may thus affect the total number of wills proved over any given space of time. In most ecclesiastical courts, for example, the number of wills proved was rising rapidly in the first three quarters of the sixteenth century, and it is often difficult to disentangle the effects of short-term crises from this long-term trend. Testamentary habits may equally have varied a good deal from one part of the country to another, so that wills in different ecclesiastical courts record the mortality experience of different samples of the population. A search for the wills of people entered in the burial registers of different parishes often reveals marked variations. In the market town of Banbury between 1558 and 157o, for example, at least I in 16 of those buried had made a will; in one of the central parishes in the city of London, St Michael Comhill, the proportion was s in 25; but in the London parish of St Botolph Bishopsgate, a few yards away, it was only I in 44) in the period '559-70.7 Such differences were no doubt to a large 

degree determined by the social composition of the populations of the parishes. St Botolph, for example, was a much poorer parish than St Michael, and fewer of its inhabitants had property to bequeath. It is the unrepresentative nature of this will-making minority which provides the most serious limitation to testamentary records. Not only were those who left wills people of some property ; they were also usually adult (and as a rule male) householders. Consequently the number of wills proved in ecclesiastical courts cannot be expected to reflect changes in mortality among the poor or young people. This is a major drawback if one is searching for evidence of an epidemic disease like bubonic plague which affected both these groups disproportionately. 



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