Wednesday, November 13, 2013

Did King Edward IV Have Type 2 Diabetes?

This article first appeared in the September 2011 issue of the Ricardian Register, Vol. 42 No. 3. 
Edward IV King of England 1461-83, the original type two diabetic?
Peter Stride
Then you conclude, my grandma, he is dead.
The King mine uncle is to blame for it.
King Richard 111, II, ii 12-131

Edward IV, second son of Richard, Duke of York and Cecily Neville, was born on 22nd April 1442. Edward IV was renowned for his radiant good looks on ascending the English throne. He was the epitome of youthful vigour and health. Why did the warrior king with an exuberant lifestyle die of natural causes at forty? The new hypothesis of diabetes is suggested.

The death of Edward IV was a pivotal point in history. The good aspects of the following Tudor and Stuart dynasties are currently the dominant English perception, but these two tragic centuries included a widespread civil war, regicide, religious schism and genocide, torture and execution of women, the risk of foreign invasion and the destruction of England’s architectural heritage.

The Young King:
Edward was a huge man. His skeleton, exhumed in 1789, measured 6 feet 3-3/4 inches, thus in 15th-century England he was nearly a foot taller than average. Contemporary writers described Edward in superlatives, "the tallest", "the fairest", "the strongest”, and was well renowned for his fair complexion and good looks. The Croyland Chronicles2 described Edward as “a person of most elegant appearance and remarkable beyond all others for the attractions of his person.” Thomas More,3 a Tudor supporter, described his appearance:

“He was of visage lovely; of body mighty, strong and clean made; howbeit in his latter days, with over liberal diet, somewhat corpulent and burly but nevertheless not uncomely.”

Ross described Edward as neither scholar nor saint, but noted his charm, courage, affability, leadership and especially his retentive memory.4

Edward’s Martial Prowess and Victories on the Battlefield:
Edward first fought in battle at nineteen, exhibiting a mature and calm control beyond his years, and beyond that of his opponents. Edward destroyed the House of Lancaster in a brilliant series of spectacular military victories. Friend and foe could see his inspiring leadership in the front line of battle, using his great height to advantage, and smashing his battle-axe at the nearest enemy.
Edward was also an outstanding battlefield commander. Edward’s knowledge of flanking movements and feints gained tactical battlefield advantages. Edward could ‘read’ a battleground and position his forces favourably. He manoeuvred his forces, at both Barnet and Tewkesbury in the dark, such that Lancastrian commanders found themselves in unfavourable situations by dawn.
Edward also had Napoleon’s favourite characteristic, luck, winning decisive battles when nature and fortune intervened. A snowstorm at Towton and heavy fog at Barnet helped turn those battles into decisive Yorkist victories. Edward fought and won seven battles, though twice he fled rather than risk a battle on unfavourable terms. Paul Murray Kendall, described Edward as “The mightiest warrior in Europe.5

Health Issues:
Edward enjoyed excellent health for many years. He had an acute illness, the sickness of the pockys,”6 perhaps measles, in 1462, but recovered uneventfully.7 Edward escaped the plague, though this disease claimed his son George in 1479. Edward‘s control over his destiny and his instinctive mastery of events deserted him in the 1469 rebellion, before he regained his throne, following the battles of Barnet and Tewkesbury. Falkus theorized that Edward had a nervous breakdown. Speculation draws parallels to Henry VI’s periodic insanity, and perhaps porphyria, present three centuries later in the Royal Family.7

Declining Health:
On regaining the throne, he ate and drank excessively. Mancini reported that he used emetics 6, but still appeared grand and regal. Commynes saw Edward in 1475 during the French Campaign and noted Edward was beginning to get fat and I had seen him on previous occasions looking more handsome.”4 Household records in 1478 state that Edward had health officers including the doctor of physic, who held consultation with the cook and stood much in the kings presence at his meals, counseling or answering to the king’s grace which diet is best according, and to tell the nature and operations of all the meats.”8 Doctor’s advice clearly fell on deaf ears in the 15th century as it does today!
Edward's health began to fail, with increasing ailments. Between 1480 and 1482, England and Scotland engaged in warfare. Edward planned to join Richard, Duke of Gloucester in both 1481 and 1482 on Scottish campaigns. He ordered eighty butts of wine for his 1481 campaign.3 Edward reached Fotheringhay Castle to plan strategy with Gloucester in 1482, but returned to London, perhaps with failing health and energy,7 never joining the campaign. A reluctance to campaign in Scotland could reflect intolerance to cold, a symptom of hypothyroidism or alternatively as common sense.
After Richard’s army captured Edinburgh, Edward granted Gloucester extensive land, income and power in the north of England in January 1483. Scofield7 described this as extravagant and ill-advised, and that “the fatal illness now fast creeping upon him had so weakened his judgement and understanding that he did not realize what he was doing.” Scofield is an acknowledged Edward IV expert. She wrote a two-volume history of Edward, and read extremely widely among primary and secondary sources about him. She did not offer any medical evidence, but believed Edward had an underlying disease.

Edward fell fatally ill at Easter 1483, initially collapsing while fishing on 30th March, and improved transiently, but weakened daily. He improved to add codicils to his will, naming his brother Richard as Protector. He then died on 9th April. The king’s barber-surgeon and physician present at his death were Jacques Freis and William Hobbes. Hobbes was appointed Serjeant Surgeon to Edward in 1461, being the first holder of this eminent office persistent today with a current appointee.9 Hobbes received a salary of 40 marks, with a meat and drink allowance. The key to this analysis is the medical knowledge base of the time, plus the experience and skills of Hobbes.
Scofield, Falkus, Hicks10 and Ross give accounts of his death, quoting the primary sources of Edward’s last days. Suggested causes include apoplexy, indigestion, typhoid, appendicitis, cirrhosis and even poisoning. The Croyland Chronicle, so often accurate, reports that the court was baffled, and gave a cryptic comment.2

“The king took to his bed neither worn out with old age nor yet seized with any known kind of malady, the cure of which would not have appeared easy in the case of a person of more humble rank.”

Mancini wrote that Edward was depressed when his treaty with the Flemings unravelled, that splendid Royal theatrical performances hid his sorrow, and that a cold was the terminal event.8

“Edward fell into the greatest melancholy, lamenting that by his inactivity the Flemings, ancient friends, had been permanently estranged from him.
“ as to mitigate or disguise this sorrow, yet was he never able altogether to hide it
“...they say there was another reason for his death was, that he being a tall man and very fat though not to the point of deformity allowed the cold damp to strike his vitals, when one day he was taken in a small boat, with those whom he had bidden go fishing and watched their sport too eagerly. He there contracted the illness from which he never recovered.

Mancini said the reconciliation between the Woodvilles and Lord Hastings occurred two days before death, though More stated this was a few hours before death.8 Commynes thought he was depressed following the Treaty of Arras, and twice states that apoplexy caused death.11 Vergil said the cause was unknown, but hinted at poison.12 Tudor historian Edward Hall suggested the malaria Edward caught in France in 1475 had “suddenly turned into an incurable quarten fever.” Thomas Basin, a French historian, said that a too-hearty dinner on Good Friday killed him.8
After Edward’s death his body was laid upon a board all naked, saving he was covered from the navel to the knees” for public display for 10-12 hours.7 No visible abnormality was recorded.

David Hughson detailed Edward’s exhumation. His skeletal measurements provided little medical information beyond the height and apparent lack of skeletal trauma.13

“The body, enclosed in a leaden and trooden coffin, measuring six feet three inches in length, appeared reduced to a skeleton.”

Possible causes of death:
There are no recorded clinical features of Edward’s terminal illness; hence his cause of death remains undiagnosed. His character fluctuations with periods of immense physical prowess, vigorous leadership and initiative, alternating with periods of inertia and poor insight impose problems in detecting developing medical problems between 1480 and 1483. Most historians believe Edward’s obesity and inactivity contributed to his ailments, and eventually to his death. His demise from an apparently minor infection suggests an underlying, undetected ailment exacerbating the acute condition. Edward fell ill after catching a cold on a fishing trip, rallied briefly, then deteriorated and died, probably of pneumonia.
Rosemary Hawley Jarman’s novel, We speak No Treason, places William Hobbes, Edward’s physician, at the bedside, setting “blood irons to the royal veins and vainly all but drained that vast body.”14 Though fictional, this is a possible contributing factor to the king’s demise. Seven generations later, excessive bleeding by equally enthusiastic but ignorant physicians contributed to the demise of Charles II.
Edward was a mediaeval sex addict, his legendary sexual activities and numerous partners suggesting a sexually transmitted disease (STD). Mancini wrote he was licentious in the extreme...he pursued with no discrimination the married and the unmarried, the noble and the lowly: however he took none by force.”8 Edward IV had ten children with his queen, Elizabeth Woodville, and perhaps five illegitimate children, between 1466 and 1480, and then no more, suggesting secondary infertility or erectile dysfunction, though Jane Shore appeared happy with his company until his death. However, syphilis, the most severe venereal disease, was not endemic in Europe for another decade15, and the genital symptoms of other STDs were not recorded in his partners, nor his partners’ other sexual contacts. Edward’s intact cognitive function on his deathbed excluded the dementia of tertiary syphilis. Henry VIII probably was the first English monarch with syphilis, though he may also have been diabetic.
All Edward’s reports indicate progressive weight gain, not terminal wasting or internal bleeding, making cancer or tuberculosis improbable. Mancini’s implication of a stroke is unlikely with intact speech, cognitive and motor functions during the deathbed scene. Increasing weight and lethargy suggest endocrine disease, with diabetes and hypothyroidism possible. Cushing’s disease and gigantism are feasible but very rare diseases of the pituitary gland, which will not be further explored in this article.16
Hypothyroidism, a deficiency of thyroid hormone, causes fatigue, weakness, weight gain, intolerance to cold, depression, constipation, impaired memory and cognitive function and decreased libido, then ultimately life-threatening depression, heart failure or coma. The Greeks were aware of goitres, but in mediaeval days diagnosis and treatment of hypothyroidism were several centuries away. Hypothyroidism in England was found in Derbyshire, the only landlocked county, from deficient iodine in the diet, hence the term Derbyshire Neck, a synonym for goitre. Edward clearly enjoyed a diet of quantity, quality and variety, including fish, excluding dietary iodine deficiency.
Annette Carson in Richard III: the Maligned King17 suggested arsenic poisoning causing Edward’s death. She reviewed many original documents, but accepts Collins'18 recent flawed medical analysis that arsenic poisoning caused Edward’s death. However, arsenic causes severe abdominal pain, diarrhoea and vomiting, thirst and excessive salivation; dryness in the throat with a hoarse voice, difficulty of speech, then convulsions, circulatory collapse, delirium and death. Arsenic is an improbable cause of Edward’s death, as these severe symptoms were not recorded.
Collins excludes diabetes in Edward IV as a wasting disease. He does not differentiate the improbable juvenile type 1 diabetes with weight loss from the possible type 2 diabetes associated with obesity. Collins incorrectly excludes “...proposed mycoplasmosis (sic) pneumoniae, an amoebic(sic) disease contracted from stagnant water” believing that pneumonia always causes death within hours, not days. Mycoplasma pneumonia are small bacteria lacking a cell wall found in animal hosts.

Polyuria or excess urine output, a symptom of diabetes, was first described three and a half millennia ago by the ancient Egyptian physician Hesy-Ra in the Ebers Papyrus, and named diabetes by the Greek Aretaeus of Cappadocia in 250 BC. The attraction of ants to diabetics’ urine was noted in India at about the same time.
The Persian physician, Avicenna, (980-1037) noted the sweet taste of diabetic urine, the abnormal appetite and erectile dysfunction in his textbook, The Canon of Medicine19, still used in 15th century England, and European Universities as late as 1650 suggesting little medical advance for six centuries. In Edward’s time medical knowledge was probably less than in the Middle East four hundred years previously. Gaddesden’s authoritative text Rosa Medicinae 2 written between 1307 and 1314, and possessed by many doctors, refers to diabetes, but omits the taste of urine.20
Getz does not mention diabetes in her Mediaeval Medicine text.21 Gilbertus Anglicus’s translation of Compendium Medicinae22 around 1240 was often used by 15th century English doctors. Anglicus stated diabetes is an vnmesurable pissing of vrinand considers it is caused by moche medling with wymen and it cometh of drinking of stronge wyne. Anglicus appears to be ‘on to something’ lost in today’s’ texts perhaps relevant to Edward! However he does not mention sweet urine. It is unknown whether William Hobbes and Jacques Freis were aware of this condition, but the available texts cast doubt on the ability of 15th century physicians to diagnose diabetes.
The English physician Thomas Willis revived the tasting of sweet urine, and in 1675 added the word mellitus. Matthew Dobson discovered sugar to cause the sweet taste of diabetic urine in 1776. William Heberden, a forefather of English medicine, wrote his celebrated text in 180223. He considered diabetes a rare wasting disease, typical of insulin dependent type 1 diabetes, having seen 20 or less cases. He omits the current common type 2 diabetes of obesity, Edward’s postulated condition.
Sir Harold Himsworth’s publication in January 1936, 543 years after Edward’s death ,clarified the distinction between juvenile type 1 diabetes and the maturity onset type 2 diabetes with obesity and insulin resistance.24 Today the association between obesity and type 2 diabetes is well understood. 20% of the Australian population are obese, 50% are overweight, 10% have diabetes or pre-diabetes, and diabetes is four times more common in the obese.
Maria de Medici, Queen of France, is also hypothesized to have been diabetic. She died in 1642, one hundred and fifty-nine years after Edward IV, still in a medical period when type 2 diabetes was unknown and when testing for sweet urine was not practised. Maria became grossly obese with overeating, died with gangrene of her right leg and skin infections. Her autopsy revealed both hardening of the arteries (arteriosclerosis) and pancreatic atrophy, both features of diabetes25. Maria’s autopsy information is not available for Edward, but both became grossly obese with overeating, and died of infections, suggestive of type 2 diabetes.

·         Edward clearly suffered from obesity and lethargy
·         He may have been depressed by his failed foreign policy, and appears uncharacteristically unmotivated in his last year of life.
·         He may have suffered a terminal pneumonia.
·         Some underlying but undiagnosed disease may have been present. Diabetes and hypothyroidism are possible explanations of increasing obesity and lethargy, which could exacerbate a mild infection, contributing to death. Diabetes is the more likely.

 End Notes:

1. Shakespeare, William. The Complete Works of William Shakespear.e Collins. London. 1961. pp 701-747
2. Historia Croylandensis translation Ingulph’s Chronicle of the Abbey of Croyland ed H. Riley Bohn’s Antiquarian Library London 1854 -The Croyland Chronicle: Part IX The Third Continuation of the History of Croyland Abbey: July, 1485 - Apr, 1486 with Notes. 
3. More, Thomas. History of King Richard III. ed Sylvester R. Yale. 1963. p3
4. Ross, C. Edward IV. University of California Press Berkeley and Los Angeles. 1974. p9, p314-315, p232, p280
5. Kendall, P. M. Richard the Third. Redwood Press. Trowbridge. Wiltshire. 1955. p414
6. Falkus, G. The Life and Times of Edward IV. Book Club Associates. London. 1981. p64, p113, p206
7. Scofield, C. The Life and Reign of Edward the Fourth. Frank Cass. London. 1923. II p161, I p264, II p218, II p359, II p365-366
8. Mancini, D. The Usurpation of Richard III. trans. C. A. J. Armstrong. (Oxford, 1969, reprinted Gloucester, 1984). p 67, p69-71
9. Talbot, C, Hammond E. The Medical Practitioners in Medieval England. Welcome Historical Medical Library. London. 1965.
10. Hicks, Michael. Edward IV. Hodder Headline Group. London. 2004
11. Commynes, P. de. Memoires de Phillipe de Commyne.s ed B de Mandrot. Paris. 1901 p304, p344.
12. Vergil, Polydore. Three Books of Polydore Vergil’s English History. ed Ellis H. Camden Society. John Bowyer Nichols and Son. 1844. pp 171-172.
13. Hughson, David. London: Being an Accurate History and Description of the British Metropolis. J Stratford. London. 1808.
14. Jarman, R H. We Speak No Treason. William Collins. Glasgow. 1971.
15. Stride, Peter. Did Perkin Warbeck’s Mercenaries Introduce Syphilis Into the UK. Ricardian Bulletin. 2010. (Dec) 4:36-38.
16. Braunwald, E, Fauci, A, Kasper, D. Harrison's Principles of Internal Medicine, 15th Edition McGraw-Hill Professional, Maidenhead, UK pp 318-323.
17. Carson, Annette. Richard III, the Maligned King. The History Press. Chalford, Gloucester. 2008.
18. Dening, J, Collins, R. Secret History, The truth about Richard III and the Princes. The Lavenham Press. 1996.
19. Avicenna. The Canon of Medicine. Trans: Gruner O, Luzac and Co. London. 1930.
20. Cholmeley, H. John of Gaddesden and the Rosa Medicinae. Clarendon Press. Oxford. 1912.
21. Getz, Faye Marie. Medicine in the English Middle Ages. Princeton University Press. Princeton, New Jersey. 1998.
22. Anglicus, G. Healing and Society in Medieaval England A Middle English Translation of the Pharmaceutical Writings of Gilbertus Anglicus. Edited Getz F. University of Wisconsin Press. Wisconsin. 1991.
23. Heberden, W. The History and Cure of Diseases. T Payne. London. 1802. p141.
24. Himsworth, H. Diabetes mellitus: its differentiation into insulin-sensitive and insulin-insensitive types. Lancet. 1936. 1:127–130.
25. de Leeuw, I. J R Coll Physicians. 2009. 39: 185-6.

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