Abstract
Frederick, Duke of York, was the hardest working prince of his day. He was Commander-in-Chief of the British Army for almost the entire period of the French revolutionary and Napoleonic wars and he used his position to implement important reforms to benefit the health of troops. He encouraged hygiene initiatives and improved medical treatment, steadily seeking to enhance the quality of medical officers and facilities. Frederick was particularly involved in the spread of vaccination, authorising the very earliest clinical trials of the process and doing all he could to promote the practice. He also played an active role in the fight to prevent and treat the ophthalmia that was decimating the British Army. As the favourite son of George III and ultimately his carer, he developed an interest in mental health and he sponsored the pioneering work of Alexander Morison (1779–1866) to expand understanding of the subject. Although not a medical man himself, Frederick was one of the most important patrons of the day and his efforts were the key to enabling others to make important advances that saved thousands of lives.
It has been suggested that the mark of a great leader lies less in his own personal brilliance or the originality of his ideas than in ability to recognise what needs to be done and then to recruit and support people able to carry out the work. Such a man was Frederick, Duke of York, a prince who was dedicated to the cause of medical research and whose interests covered vaccination, mental health, ophthalmology and surgery.
Frederick was born in 1763, the second son of George III. From 1780 to 1786 he lived in Hanover where he studied military theory and practice. Upon his return to England he fell under the malign influence of his elder brother, the Prince of Wales. This period of his life ended when war broke out with France in 1793 and Frederick took up his military career. As with many young men, it was the experience of going to war that forced him to grow up and exposed him to sights and problems from which as a prince he would normally have been shielded. In 1795 he was placed in charge of the entire British Army, a position he was to hold with a slight break until his death in 1827. Frederick continued his life as a working royal using his position to push through much needed changes in the army and to promote a variety of charitable endeavours. He regularly worked from ten in the morning to eight at night demonstrating, as Colonel Crawford told the Commons, ‘a degree of laborious assiduity rarely to be met with in any man, and still more rarely perhaps in a man of his high birth'. 1
Welfare of the troops
There was no doubt that the army Frederick led in 1793 was ill-equipped. One officer described it as ‘the most undisciplined, the most ignorant, the worst provided army that ever took the field'. 2 Fundamental items such as winter coats, kettles and tents were missing and these were only supplied after Frederick’s personal insistence. 3 When he discovered that the hospital supposed to care for his men only had the standard thirty pounds contingency allowance, notwithstanding more than ten thousand casualties, he spent his own money to buy supplies. 4 At Tournay he witnessed men being laid at least two to a bed with the dysentery and fever cases mixed together and hospitals without water to drink or clean wounds. One officer described the resulting high death toll as being the result of ‘inhuman treatment and neglect'. 5 Unsurprisingly, when Frederick returned to England and took charge of the army, medical reform was high on his agenda.
He began by appointing Robert Jackson (1750–1827) as Physician to the Forces, a choice that broke the monopoly of the College of Physicians and showed Fredrick’s preference for practical experience. Jackson was insistent that the rate of one medical officer per five hundred men was insufficient, something with which Frederick agreed wholeheartedly. Yet, recruiting staff was difficult due to low pay rates. Despite efforts to attract students from Dublin with promises of a generous bounty, pension and travel costs, the government had to agree large pay increases in order to secure men. The pay of regimental surgeons, for example, went from four shillings a day to ten.
Alarmed, however, by the fact that anyone with the money could simply buy a commission as a medical officer, in 1804 Frederick ordered the Army Medical Board to ensure all potential surgeons were thoroughly examined for ‘a complete knowledge of pharmacy and the treatment of medical cases'. Four years later he demanded they test more rigorously. 6 In 1816 testing was extended to Hospital Mates who were to have studied medicine, anatomy and chemistry as well as spend a minimum of 3 years in surgical work.
Frederick introduced uniforms for medical officers so they could be easily identified in battle and he ordered that each regiment supply regular returns relating to sickness. He introduced a health check for army recruits before they joined up and inspectors for hospitals. He issued new regulations on the care of the sick including such basics as regiments having carts to transport the sick and the need to have separate toilet facilities. He even secured the agreement of the government to pay for medicine in 1796, something that previously had been docked from the soldiers' own pay. Frederick also supported the use of field hospitals despite opposition from the Army Medical Board. In 1810 his assistant confided to Wellington (1769–1852) that ‘The Medical Board is the torment of his life but so long as they continue as a Board, the Duke must suffer them'. 7
Frederick encouraged innovation too, particularly at the military hospital that was erected and named after him in 1795. There, Joseph Carpue (1764–1846) performed the first plastic surgery in 1814 to reconstruct the nose of Captain Latham, and Frederick sent his own carriage daily to take Latham out for fresh air to aid his recovery. 8 He supported George Guthrie (1785–1856) in his pioneering work on eye diseases, syphilis and gangrene. Frederick was keen to see a Chair of Military Surgery established in England as it was in Edinburgh in 1806 but without any money forthcoming he allowed first Carpue and then Guthrie to offer lectures at the York Hospital from 1800 onwards urging army doctors to take full advantage of the free training offered. This ended when the York Hospital was closed in 1819, its work being transferred to Chatham. 9 York Hospital was situated approximately where Sloane Gardens may now be found, to the east of Lower Sloane Street.
Smallpox vaccination
Since the demise of plague, smallpox had been the biggest scourge in the British Isles. The London Bills of Mortality showed that around a fifth of all deaths in the capital were due to smallpox and there were regular epidemics across the country. Although the disease was often associated with young children, adults who caught it were particularly vulnerable with around one in four patients dying. 10 It not only killed thousands of people but it scarred millions more. Dr Samuel Scofield wrote ‘The smallpox when it does not destroy life very often renders it miserable through the remainder of existence by producing irremediable affections as lameness, blindness, deafness, scrofula, fits, permanent mania and many other anomalous diseases'. 11 In 1808 it was stated that 40%of those who caught the disease would be left maimed or blind. 12
Frederick’s interest in smallpox began in 1788 when he became a Governor of the London Smallpox Hospital at St Pancras. In 1799 he became its President, a role he held until his death almost thirty years later. 13 At the outset the concerns of the hospital revolved around care of the sick and inoculation. Frederick had been inoculated himself at the age of two and had been very little affected by the experience though his elder brother had been quite ill. 14 All the royal children were inoculated, but tragedy struck in 1783 when the 4-year-old Prince Octavius died as a result. 15 The risks had always been known but a death rate of around one in six hundred from inoculated smallpox was much better than one in six from natural smallpox and for this reason the hospital continued to promote the practice even though some disapproved. Frederick received one letter which stated ‘Your hospital affords a constant and inexhaustible source of contagion: … Were you aware of the mischievous tendency of the practice pursued there, you would not, you could not support such an abuse'. 12
However, Frederick was extremely well informed about the subject which explains his excitement when introduced to vaccination by the publication in June 1798 of Jenner’s paper An Inquiry into the causes and effects of the Variolae vaccine or the cowpox. Frederick’s physician, George Pearson (1751–1828), conducted clinical trials from 1798 at St George’s Hospital and in 1800 set up a dispensary in Golden Square. Frederick originally agreed to be its patron but subsequently withdrew following Pearson’s dispute with Jenner and the decision to charge for the vaccine matter. As President of the London Smallpox Hospital, Frederick authorised the trials carried out by William Woodville (1752–1805) in 1799 and vaccination replaced inoculation at the hospital the following year. 16
Aside from being shown to protect against smallpox in almost every case (the Royal College of Surgeons found one in three thousand were said to be left unprotected 17 ), vaccination had the key advantage that it was safer and easier. Accounts of inoculation in the early eighteenth century show how doctors required patients to undergo five or six weeks of blood letting and purging and to adopt a highly restrictive diet before the actual treatment. This was followed by weeks of illness that might include nausea, temporary blindness and pain, a period during which they were infectious to those about them. 18 Inoculation, therefore, was impractical for adults who had to earn a living. Vaccination, by contrast, required no time away from work, no dieting or blood letting, and took only moments to perform.
Frederick was so impressed by what he had heard that he invited Edward Jenner (1749–1823) to meet him. At a subsequent meeting on 15 April 1800 he asked Jenner to vaccinate the men of the 85th Foot in Colchester together with their wives and children. The project did not get off to a good start due to sickness in the regiment so it was not until mid June that the full vaccination took place.
19
The newspapers reported ‘In so mild a manner did the disease show itself that scarcely a man was off his duty during the time'.
20
A few days later, all involved were then inoculated with the smallpox and ‘no constitutional symptoms, not the least effect was produced' in anyone.
21
A similar exercise was carried out with the Coldstream Guards and by October 1800 it was noted that Frederick had caused ‘a considerable portion' of the army to be vaccinated.
22
This included men serving overseas in Malta and Gibraltar, Frederick despatching doctors in July 1800 with his own letter of personal recommendation.
23
In 1801 doctors were sent to vaccinate Abercrombie’s army in Egypt.
24
On 15 November 1803 Frederick went a step further and issued the following instruction to every regimental surgeon in the entire army: The inoculation of the cow pock is to be constantly practiced. Let every man who does not bear the mark of the small pox either by inoculation or otherwise be subject to the trial of the cow pock (if it has not already been done) after the manner described in Appendix no 5.
The instructional appendix was written by Jenner himself. 25
Frederick would have issued the order sooner but for the problem that existed in obtaining sufficient matter. By 1803 there were almost half a million men in the army or attached to it as volunteers, a more than tenfold increase from when the first trials of vaccination had begun. Given cowpox was a relatively rare disease, obtaining matter was not straightforward. The mass vaccination of soldiers and their families represented a significant challenge and caused doctors to experiment with methods of transporting lymph including via dried pieces of thread and glass plates. 26 Yet an order from the King’s son, and that issued during wartime, concentrated the minds and directly encouraged innovation.
To Frederick’s disappointment and anger, the regimental surgeons did not all follow his instructions. Deaths from smallpox continued to affect the army. One such was George Scott, an 18-year-old soldier who died in Ramsgate in April 1804. 27 A few weeks later Frederick issued a further order through his Adjutant-General to all officers requiring them to make sure that the men were made aware of the benefits to be gained by being vaccinated and that regimental surgeons were reminded of their duty. 28
Probably the main reason that the order had not been universally adopted was because some surgeons thought it was a waste of time. Back in 1781 the surgeon to the Cheshire Militia reported that 95% of the men had already had smallpox, either naturally or through inoculation. 29 While such a high proportion was common in cities, it was not the case in small towns or villages and, with the army taking on large numbers of men from all across the country, Frederick knew it was essential to take steps to protect them. A serious outbreak of smallpox could decimate a regiment and so weaken Britain’s chances of winning the war. George Cleghorn had been with the troops in Minorca in 1742 and 1746 when casualties among common soldiers had been particularly high and he wrote ‘three fourths of the infected, in spite of all that could be contrived for their preservation perished between the sixth and the fourteenth days of the fever. And the most of those who survived remained blind, consumptive or lame with caries of the bones, sordid ulcers, etc'. 30
As well as his promotion of vaccination in the army and his role at the London Smallpox Hospital, Frederick was actively involved in the Royal Jennerian Society. The King was patron of the national organisation but Frederick was President as well as patron of local groups including the Royal Somerset Jennerian Society. 31 He chaired meetings, engaged in correspondence and attended events. Most important, he visited hospitals. Today, royal visits to the sick are not regarded as unusual but at that time it was extraordinary. The fact that Frederick was visiting people afflicted with the most dangerous disease of the era and talking to them, discussing case notes with doctors, was exceptional. 31 The visits were also vital to allay fears about the safety of vaccination. The popular press had published such nonsense as Gillray’s 1802 print called The Cow Pock which suggested that all sorts of monstrous diseases would follow vaccination while Moseley claimed that ‘the people of England are becoming like the inhabitants of a wilderness… wild, with horns on their heads, very hideous and speak not but rout as swine'. 33 Frederick’s work demonstrated its safety and value.
Eyesight
Everybody wants good eyesight but Frederick was particularly aware of the problems caused by sight loss because he saw the problem at close quarters. His own father had needed glasses from at least 1788 and was totally blind for the last ten years of his life. 34 His uncle Edward, the previous Duke of York, had suffered severely from occulocutaneous albinism and been almost blind by age twenty-seven. 35 Across the country, thousands had been blinded by smallpox and numbers were increasing due to the ophthalmia which had afflicted particularly the troops sent to Egypt and also those in Malta and Gibraltar. Lieutenant Colonel Robert Wilson said that in 1801 alone 160 had been permanently blinded while 200 men had lost at least one eye. Vetch spoke of the 52nd Regiment which had over six hundred cases (including relapses) from seven hundred men with one in eight of the men losing one or both eyes. 36 By 1818 more than five thousand men had been invalided out of the army because of blindness and the government was forced to commit more than a hundred thousand pounds to pensions for them. A typical payment was thirty pounds a year plus another twelve to a guide employed to look after the said blind pensioner and lead him about. The men who lost one eye received no money but instead were transferred to garrison duty. Patrick MacGregor wrote in 1811 that ophthalmia in the army had ‘at different periods materially interfered with its discipline and efficiency. It has crippled many of our best regiments to such a degree as for a time to render them unfit for service'. 37
The problem was exacerbated by lack of understanding of the nature of ophthalmia, the various types, the causes and what could be done to help. Sir Sydney Smith collected French works on the subject and sent them back to England, asking that they be translated in the hope they might help but the French were not much better informed. 38 Victor Stoeber (1803–1871), who pioneered ophthalmology in France, admitted there had been only three lectures a year on eyes when he was a medical student in Paris and it is likely there were fewer in the late eighteenth century.
Frederick knew that the only way in which the situation could be improved would be if there could be proper controlled studies and to that end he supported initiatives that would at once help the afflicted and improve the education of those required to treat them. In 1804 he became involved in the establishment of the first specialist eye hospital, The Royal Infirmary for Diseases of the Eye, the brainchild of Jonathan Wathen Phipps (1769–1853) who had treated the King since 1796. Shortly afterwards John Cunningham Saunders (1773–1810) opened the London Dispensary for Curing Diseases of the Eyes and Ears (later to become Moorfields Eye Hospital). Frederick was not initially involved in this but in 1815 he accepted a request to become its first patron. As such he paid a leading role in the campaign to purchase new premises, the foundation stone being laid at Moorfields on 2 May 1821. Both hospitals treated on average two thousand patients a year free of charge including many soldiers, Moorfields also offering a teaching service from 1810. In 1816 Frederick became patron of George Guthrie’s Royal Westminster Infirmary set up ‘for the relief of the poor and as a school of instruction.' 39 By 1825 it had treated more than ten thousand people and trained many army surgeons, all of whom at Frederick’s insistence had received instruction free of charge. 40
At the start of 1810 Frederick established a council comprised of senior members of the Army Medical Board and of leading eye specialists to deliberate on means of preventing and curing ophthalmia. Their recommendations for prevention included the immediate isolation of anyone affected, more frequent and more thorough laundry of the bedding for those affected and an absolute ban on men sharing the same towels or washing their faces in the same water. 41 These were sensible measures and Frederick wasted no time in sending them out to all commanding officers and army medical staff, but they were difficult to follow, particularly during a war. As Mackesy noted, segregation in military hospitals was normally impossible which meant that ophthalmia continued to make ‘extensive and destructive progress' as for example in the 62nd Regiment which had almost two hundred cases at Palermo in 1813.
With regard to treatment, the methods generally employed involved putting the patient on a sparse diet and subjecting him to several hours of vomiting. This was followed by bleeding and purging which was designed to lessen the inflammation. Leeches would be applied liberally around the eye and a solution of sugar, lead and white vitriol would be applied to the eye itself and citrine ointment to the lids. There was also some use of opium. 42 Fierce conflict broke out between surgeons in the regency period about what was the most effective operation and who pioneered what but Frederick wisely kept out of it. His concern was with the patients and not with politics.
Mental health
It is sad that almost the first thing remembered about King George III is that he was mad. Modern scholars have attempted to deny that by suggesting he had porphyria or bipolar disorder 43 but contemporaries thought he was mad and this caused questions to be asked about insanity and how to treat it. Frederick was one of those who was most keen to learn more about the subject, not from any disinterested scientific standpoint but because he was concerned about his father.
The King’s first lapse into insanity began in 1788 when Frederick was twenty-five. At first he thought his father’s agitation was due to overwork and he believed a rest would suffice but this was not to be. A week later he witnessed his father attack his elder brother and it was claimed that Frederick had been forced to step in to restrain him amid the tears of his mother and sisters. If that was not traumatic enough, the next night he saw his deeply confused father again become violent. Frederick spent a month at Windsor, some days being able to have rational conversations with him but on other days finding his father did not know him and he gibbered with terror as a result of hallucinations. Fanny Burney (1752–1840), who waited on the Queen at the time, wrote: ‘all was ignorance, mystery and trembling expectation of evil'. 44
Conventional treatments of the day were tried including cold baths, blisters and quinine, but to no avail. Eventually, following a meeting in Frederick’s apartments, the decision was taken to move the King to Kew where he could be treated in greater privacy. It was at this point that the services of Dr Francis Willis (1718–1807) were secured who introduced a new regime involving straitjackets and the complete segregation of the King from his family. Despite the king regularly asking to see Frederick, it was to be three months before they saw each other again.
Further episodes of madness occurred in 1801 and 1804 and from 1810 onwards. The first of these episodes was handled by the sons of the original Dr Willis but, following a dispute, in 1804 the care of the king was entrusted to Simmons. On the last occasion, against the wishes of the royal princes, the Willises were called back. William Heberden (1710–1801) led the opposition and together with Frederick questioned the treatment on offer but the Queen decided to put her trust in the Willis family.
It was a difficult position for Frederick. He was not a doctor and could only rely on the opinions they offered but he was suspicious. He noted the medicines they were using seemed to be making the King worse. 45 In this he was proved correct two centuries later when analysis of one of the King’s hairs revealed huge amounts of lead, arsenic and mercury. 46 He continued to visit his father when he could but the encounters were uncomfortable. In 1811 he reported starting a conversation upon one matter but said the King ‘soon flew off from that subject and then ran on in perfect good humour but with the greatest rapidity and with little or no connection upon the most trifling topics, at times without the least regard for decency'. 47
For the Willises this reaction was proof of why the King needed to be kept in isolation. Family visits were stopped and the King mourned the loss of his sons whom he believed were dead. The strict regimen imposed remained in force until the end of 1818 when the Queen died and Frederick was invited to take charge. He at once announced his intention of visiting his father regularly but, with the King now blind and increasingly deaf, communication became even more difficult. Frederick stopped the practice of keeping the King in the cold all the time and ordered fires to be lit and the King’s clothes to be warmly lined. He required medicine to be hidden in food rather than forced down and he encouraged allowing his father to move about and do things. He reported finding the King ‘amusing himself with playing upon the harpsichord and singing with as strong and firm a voice as ever I heard him and seemed as happy and cheerful as possible'. 48 This was precisely what Heberden had recommended years before. Heberden had sought to read newspapers to the King and engage him in conversation to ‘place him in a situation that may call forth the energies of his mind and divert the wanderings of fancy not by vain expostulation but by objects of natural interest'. On the advice of the Willises the Queen had banned this. 49 It was, however, too late and on 29 January 1820 the King died.
Heberden’s belief in the importance of stimulus was based upon his study of Pinel. 50 Philippe Pinel (1745–1826) had advocated the need to treat each patient individually and kindly with restraint only used in violent cases. Pinel had also advocated keeping patients warm and had opposed bleeding and the use of mercury though he favoured purges. 51
Another man to take an interest in Pinel’s work was Alexander Morison (1779–1866) who visited his hospital in 1818. In February 1823 Frederick appointed Morison as his physician and he encouraged him to lecture on his theories. 52 In November that year Morison began a series of lectures in Edinburgh which became an annual event. In March 1826 he started to do the same in London. This was the first time that anyone had offered to teach on mental illness and, aware of the paucity of material on the subject, Morison published his lectures in 1825. In 1828 he published his case histories urging others to follow suit to increase understanding and reduce the stigma of mental illness. 53 Frederick’s patronage of Morison showed his continued dedication to the cause of medical education.
Frederick’s experience of mental problems was not restricted to his father. His own experiences of war had changed him dramatically and he understood the strains placed upon those who fought. One of his first decisions was to insist that all regiments had an army chaplain and that this person was willing to go to war with the men. This directive caused such horror that all but two chaplains resigned immediately. When he found replacements hard to recruit due to the low salaries on offer, Frederick secured an increase from the Treasury. 44 Although his faith in spiritual guidance contributing to mental wellbeing was laudable, the chaplains were unable to prevent a massive increase in mental problems. John Haslam (1764–1844) of the Bethlehem Hospital, popularly known as Bedlam Lunatic Asylum, reported that they had men ‘pouring in from the Transport Board and the War Office' and in 1819 the army established its own specialist hospital at Fort Clarence in Rochester. 55 In 1816 a request was sent out that future medical officers be experienced in ‘mental derangement'. 56 A further sign to Frederick of the traumatic effect of war came in 1800 when James Hadfield, his orderly in the 1793–1794 campaign, tried to assassinate the King, alleging that voices in his head had told him to do so. Frederick spoke with Hadfield himself and testified on his behalf, leading to Hadfield being the first person to be found not guilty on grounds of insanity.
Conclusion
The work of Frederick, Duke of York, has been unjustifiably forgotten today due to a nursery rhyme and a scandal. ‘The Grand Old Duke of York' is a verse that portrays an inept and indecisive military leader. It could be about Frederick but is more likely to have been composed about James, Duke of York, who led ten thousand men at the Battle of the Dunes in 1658. The scandal of 1809 arose because Frederick’s mistress was, unbeknown to him, accepting large sums of money alleging she could obtain army commissions due to her special relationship with him. It was all untrue and later shown to be a political plot but by then the damage was done. As today, newspapers publish allegations in banner headlines and yet publish the confirmation of someone being cleared in a small paragraph on an inside page. Frederick is best known today for his statue in the Mall (Figure 2) and for being uncle to Queen Victoria, yet his contribution to medicine should not be overlooked. His sincere desire to help improve his fellow man led to him funding research and encouraging education and innovation that directly saved lives. He was patron of no fewer than nine hospitals and two dispensaries and of the first ever convalescent home.
57
He started an involvement in health issues and hospital visiting which continues in the royal family today, the current Duke of York also being an active patron of several medical research charities and of the Royal National Orthopaedic Hospital. Frederick was, as Sir Walter Scott declared, ‘a prince and a great man.'
58
Frederick, Duke of York in 1815. The Duke’s statue in The Mall, London.
