The death of King Charles II

After the final defeat of the Royalists at the Battle of Worcester in 1651, the young Prince Charles fled to France, where he stayed until the Restoration of the Monarchy in 1660. He was crowned King on St Geroge’s Day, 23 April 1661.

Charles loved hunting and walking his spaniels. He was a patron of the sciences and founded the Royal Mathematical Society in 1684. But perhaps his greatest love was that of beautiful women. Among his mistresses he counted Hortense Mancini, Duchess of Mazarin, Moll Davis, Barbara Palmer, Duchess of Cleveland,  Louise de Kérouaille, Duchess of Portsmouth, and, most famous of all, Nell Gwyn.

Charles married a Portuguese Princess, Catharine of Braganza in 1662. The marriage proved loving but barren. Charles had children by some of his many mistresses, but none by his wife.

The King’s last illness

On 1 February 1685, instead of walking his spaniels as usual in St James’s Park, a park whose construction he had himself funded, Charles, plagued by a leg ulcer, perhaps secondary to gout, went for a carriage ride. That night he went to bed, slept uneasily, and awoke at about 7 a.m.

 Charles gave ‘the dreadfulest shriek’ and developed convulsions, pallor and speechlessness. His physicians were soon in attendance. They bled him 16 oz (450 mL or about a pint); they cupped him, scarified him, and blistered him with cantharides; they gave him emetics, cathartics, and enemas. They bled him again, 8 oz. All before noon. In the afternoon, they gave him sacred bitter powder + compound peony water + bryony compound and white hellebore.

The next day, Tuesday 3 February, the King had another convulsion. His doctors prescribed sacred tincture 6 hourly, manna + cream of tartar 6 hourly, sal ammoniac in antidotal milk water as required, and a julep (a sweetened medication) of black cherry water + flowers of lime + lily of the valley + paeony + lavender + powdered pearls + sugar. They bled him another 10 ounces and blistered him. They followed this with more mallow root + barley water + almonds + melon seeds and bark of elm. Wednesday was a quieter day, and his doctors did not think further medicine necessary until the evening, when they gave him white tartar + white wine + senna + manna + chamomile + gentian + nutmeg, followed by spirit of human skull. On the Thursday news came of an intermittent fever in town, and they took prophylactic measures, including Peruvian bark + antidotal milk water + cloves. They also gave him more spirit of human skull, Raleigh’s stronger antidote (stronger because it contained more herbs than any other remedy), Goa stone, and sal ammoniac.

The next day, Friday 6 February, was his last. He apologised to his doctors for being “an unconscionable time dying”, enjoined his brother, the Duke of York, not to let poor Nelly starve, and confessed that “I have suffered very much, and more than any of you can imagine. My business will shortly be done”. He asked to see the light of the rising sun, after which he became acutely breathless and was bled another 12 oz. His speech failed, he became unconscious, and he died just before noon.

The following post-mortem findings were reported by his physician Sir Charles Scarburgh:

• On the Surface of the Brain the Veins and Arteries were unduly full
• The Cerebral ventricles were filled with a kind of serous matter
• The substance of the Brain itself was quite soaked with similar fluid
• On the right side the Lungs and Pleura were firmly adherent to the chest-wall
• The heart was large and firm and quite free from malformation
• The Lungs were charged with blood
• The Liver was livid in colour [engorged with blood, as were] the Kidneys and Spleen

Most of these changes were probably terminal, but the engorgement of the blood vessels in the brain and the presence of fluid (cerebral oedema) suggest that he might have had a cerebral infection, such as a viral encephalitis.

Rumours at the time suggested poison, but the King was popular and there is no evidence of that. The history of gout can be relied upon, and that could have caused renal damage and functional impairment. Others have suggested that he had what later came to be known as Bright’s disease, which we now recognize as a syndrome that can be caused by a range of kidney diseases, such as glomerulonephritis, and which we would nowadays call nephrotic syndrome, with renal impairment, peripheral oedema, and proteinuria (coagulable urine as Bright described it). Bright’s disease could have explained Charles’s pleural adhesions and convulsions, the latter because of uraemia, but it was often accompanied by enlargement of the heart, which was not found. High blood pressure as a result of kidney disease could have caused a stroke, but there was no post-mortem evidence of that. A suggestion that he died of mercury poisoning is based on dubious supposition and weak evidence.

My own interpretation is shown in the figure below. It is clear that Charles had repeated episodes of gout. The ulcer on his foot may have been due to that. Chronic gout, untreated, would almost certainly have led to deposits of uric acid in the kidneys and chronic renal impairment. The dehydration that his physicians would undoubtedly have induced during his final illness, by bleeding, cupping, scarifying, blistering, and clystering him, and by giving him a range of emetics and purgatives, would have caused acute renal insufficiency, which could have caused acute posterior reversible encephalopathy syndrome, explaining the cerebral oedema that was found at post mortem.

Could modern medicine have helped?

The many manoeuvres Charles’s physicians performed, such as blistering, cupping, scarifying, and the administration of purgative and emetic medicines, were intended to restore the balance of the bodily humours, supposed by Galenic theory to be out of balance during illnesses. Some of the medicines were used to counteract the scalding effect of cantharides on the urine. Spirit of human skull, used to treat convulsions, was, according to Pliny the Younger, water drawn from a spring in the night, and drunk from the skull of a man who had been slain and whose body remained unburnt. Peruvian bark and Goa stone were used to counteract fever, and the former might have been effective, since it contains quinine.

However, most of these measures would have been ineffective or even dangerous, depending on the doses used and the frequency with which they were administered.

In contrast, much could have been done today to treat Charles and to have prolonged his life considerably, and with good quality.

His chronic gout would have been alleviated by medicines that increase uric acid excretion or reduce its production; acute attacks would have been relieved by non-steroidal anti-inflammatory drugs or corticosteroids.

Chronic kidney disease could have been prevented with antihypertensive drugs, managed, if severe, with renal replacement therapy, i.e. renal dialysis, and eventually cured by renal transplantation.

But perhaps most importantly for the history of the nation, Catharine’s infertility could have been treated. Had Charles had an heir, his brother James would not have acceded to the throne in 1685, giving way to his Protestant son-in-law and nephew William of Orange, who took the throne by force in the so-called “Glorious Revolution” of 1688. English and Irish history would have taken a much different course.

Conclusion

It is likely that Charles died from problems that his physicians at that time could not have cured, even had they known what they were and what caused them. However, it is equally likely that they hastened the end when it came.