Did the growth of knowledge defeat the resourcefulness of disease? Hardly. Voltaire estimated the average longevity of human life in his time at twenty-two years.11 The slums of the growing cities made for a high rate of infantile mortality, sometimes reaching fifty per cent.12 In London fifty-eight per cent of all children died before their fifth birthday.13 The abandonment of infants was widely practiced. In the eight years 1771–77 nearly 32,000 children were admitted to the Paris Foundling Hospital—eighty-nine per day; of these babies 25,476 (eighty per cent) died before completing their first year. A contribution to infant mortality was made in the eighteenth century by the spread of dry-nursing—the replacement of the breast of mother or wet nurse by the bottle. Sir Hans Sloane reckoned the death rate of bottle-fed infants as three times that of the breast-fed. The new method became especially popular in the upper classes of France, until Rousseau’s Émile (1762) made breast feeding fashionable.

Abortion and contraception continued. The linen sheath, recommended by Fallopio in 1564 to prevent venereal infection, was used in the eighteenth century to prevent conception.14 Dr. Jean Astruc, in De Morbis venereis (1736), mentioned debauchees who “have been employing for some time sacs made of fine, seamless membrane in the form of a sheath, … called in English ’condum.’”15 A Mrs. Phillips in 1776 issued handbills in London announcing that her shop had a full supply of such “implements of safety, which secure the health of her customers.”16 Despite these “machines,” as they were called, venereal disease took its toll in every class. Lord Chesterfield warned his son to be careful, for though “in love a man may lose his heart with dignity, … if he loses his nose he loses his character into the bargain.”17

We who live after Jenner can hardly imagine what a curse smallpox was before he converted the Western world to vaccination. Voltaire calculated that “in a hundred persons that come into the world, at least sixty contract smallpox; of these sixty, twenty die … and twenty more keep very disagreeable marks of this cruel disorder as long as they live.”18 Between 1712 and 1715 three heirs to the French throne died of smallpox. The Prince de Ligne thought that 200,000 inmates of nunneries and monasteries had sought refuge there from the humiliation of smallpox disfigurement.19 The disease reached epidemic proportions in Paris in 1719, in Sweden in 1749–65, in Vienna in 1763 and 1767, in Tuscany in 1764, in London in 1766 and 1770.

Epidemics in general were now less severe than in earlier centuries, but they remained among the hazards of life. They were more formidable in the countryside than in the cities, despite urban slums, for the peasants could seldom afford medical care. Epidemics of typhus, typhoid fever, and smallpox killed eighty thousand persons in Brittany in the one year 1741.20. In 1709 bubonic plague carried off 300,000 persons in Prussia; it reappeared with less intensity in the Ukraine in 1737, in Messina in 1743, in Moscow in 1789. Scarlet fever, malaria (mal aria, bad air), dysentery, were common, especially in the lower classes, where they were favored by poverty of public sanitation and personal hygiene. Epidemics of contagious puerperal fever occurred in Paris, Dublin, Aberdeen, Thurgau, and Bern. Influenza, which the French called la grippe (adhesion), reached the epidemic stage at various times in Italy, Sweden, and Germany. Occasionally it led to infantile poliomyelitis, as in the boy who became Sir Walter Scott. Pneumonia, diphtheria, and erysipelas now and then neared epidemic proportions. Whooping cough, which seems so minor now, was widespread and dangerous, especially in northern Europe; in Sweden forty thousand children died of it between 1749 and 1764. Yellow fever came in from America, and rose to epidemic form at Lisbon in 1723. To these and a hundred other ailments the ladies of the upper classes added “the vapors”—a confused mixture of nervous exhaustion, hypochondria, insomnia, and boredom, rising at times to hysteria.

Against such public enemies the governments provided some measures of sanitation. But offal was still for the most part emptied into the streets. Water closets appeared in Paris at the beginning of the century, but only in a few houses; they were almost entirely lacking elsewhere on the Continent. Bathrooms were a luxury of the rich. Public baths were probably less numerous than in the Renaissance. Hygiene made more progress in armies and navies than in cities. Sir John Pringle advanced military medicine (1774), and James Lind of Scotland revolutionized naval hygiene (1757). In Anson’s expedition of 1740 some seventy-five per cent of the crews were at times disabled by scurvy. In an epochal treatise on that disease (1754) Lind pointed out that orange or lemon juice had been used in treating it by the Dutch in 1565 and by Sir Richard Hawkins in 1593; through Lind’s influence this preventive was introduced in the British navy (1757). In Cook’s second voyage, lasting over three years (1772–75), only one case of scurvy proved fatal. In 1795 the use of citrus juices or fruits was made obligatory in the British navy (hence the name “limey” for a British sailor or soldier); thereafter naval scurvy disappeared.

It was a milestone in eighteenth-century humanitarianism when Victor Riqueti, Marquis de Mirabeau, laid down the principle (1756) that the health of the people is a responsibility of the state. Johann Peter Frank, who began life as a poor child abandoned at a street door, proposed a complete system of public medical service in his System einer vollständigen medizinischen Polizei (1777–78). These four volumes, the “noble monument of a lifelong devotion to humanity,”21 described the measures that should be taken by any civilized community to dispose of waste, to guard the purity of water and food, to maintain hygiene in schools and factories, and to protect the health of women in industry; for good measure the doctor prescribed the taxation of bachelors, gave advice on conjugal hygiene, and demanded the education of children in the principles of health. Napoleon was one of those who appreciated Frank’s ideas; he begged Frank to come and serve Paris; Frank remained in Vienna.

Hospitals lagged far behind the need for institutional care of disease. Their number grew, but their quality declined. England in particular multiplied its hospitals in the eighteenth century, but all of them were maintained by private contributions, none by state endowment.22 In Paris the leading hospital, the Hôtel-Dieu, received 251,178 patients in the eleven years from 1737 to 1748; of these, 61,091 died. The demands on this “Mansion of God” led to its putting three, four, five, even six persons in the same bed; “the dying and those on the road to recovery lay next to each other; … the air was tainted with the emanations from so many diseased bodies.”23 It was one of the many beneficent acts of Louis XVI that in 1781 he decreed that “henceforward 2,500 patients should have a separate bed, that five hundred should sleep in double beds divided with a partition,” and that there should be special rooms for the convalescent.24 Nevertheless, seven years later the hospital had single beds for only 486 patients; 1,220 beds held four or more patients, and eight hundred patients lay on straw.25 In Frankfurt-am-Main and other cities the air in the hospitals was so fetid that “physicians declined hospital service as equivalent to a sentence of death.”26

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