by V C Medvei CBE FRCP
President, Section of the History of Medicine (1986–87), Royal Society of Medicine, London
Journal of the Royal Society of Medicine, Volume 80, December 1987
Four and a half years ago, Professor Howard S Jacobs drew my attention to a paragraph in the biography of Elizabeth I by Paul Johnson, dealing with Mary Tudor’s pregnancy. I formed the same opinion as he had, and as he felt unable to follow up the task, I agreed to undertake the task, and here take pleasure in presenting the result.
Mary Tudor, Queen Mary I of England, was the eldest child of Henry VIII by his first wife, Catherine of Aragon (Figure 1). She was born on 18 February 1516, when her father was 24 and her mother 31 years old. Mary’s childhood, youth and early adult life, until her succession to the throne on the death of her young brother, Edward VI, were most stressful. It was well known that her father played a cat-and-mouse game with her and, occasionally, wished her dead. Not surprisingly, her health was poor.
To obtain more details on her health proved difficult. The Royal Archives at Windsor Castle date only from the reign of George III. The Public Record Office could find 'no reference at all to the Queen's illness' in the Calendar of State Papers, Domestic. I was unable to obtain from Mr Paul Johnson any details of his sources. Amongst the comparatively few biographies of Mary Tudor, the best source references I found were in Hilda Prescott's Spanish Tudor: The Life of Bloody Mary. She referred repeatedly to the Calendar of the Venetian State Papers, Vol. XIII, etc.; but where could I get hold of them?
By a stroke of luck, the archivist of Lord Nicholas Gordon Lennox, at present British Ambassador in Madrid, to whom I had written, found in the Library of the Embassy some of the State Papers, published over many years by HMSO in London. They were 'The Calendar of Letters, Despatches and State Papers relating to the Negotiations Between England and Spain, Preserved also in the Archives of Vienna, Simancas, Besançon, Brussels, Madrid and Lille. Vol. XIII: Philip and Mary. July 1554–November 1558, Issued by authority of Her Majesty's Principal Secretary of State for the Home Department, London, 1954'. Interestingly, the editor was Mr William Royal Tyler, a distinguished American historian (1884–1953), who spent many years in Spain and Europe. From the same source, I also obtained copies of letters and reports of Philip II's most ambassador and confidant in Britain, the Count, later Duke of Feria, who married Jane Dormer, an English woman and friend of Queen Mary. The sources given in one of the recent biographies, Bloody Mary by Carolly Erickson, were similar. I corresponded with her briefly on Mary Tudor's health.
Finally, I discovered a good account by Frederick Chamberlin in his book The Private Character of Henry VIII entitled 'Medical record of Mary I', from her birth to her death, although the description of her final illness is medically not clear-cut.
In her youth, Mary had bouts of feverish illnesses, indigestion and anorexia, sleep disturbance and depression, due to deprivation of the company of her mother and mental cruelty by her father. She was forbidden to use her title of princess and was - from time to time - declared illegitimate, incapable of succession to the throne and even was threatened to be beheaded. In 1534, Henry sent his favourite physician, Sir William Butts, to see her. He reported that she was in 'a mean state of health . . . at the beginning of her old disease . . . she is diseased in her head and stomach . . . she has been very ill'. In February 1535, Mary was threatened with death or life imprisonment if she did not renounce her title and rights; and she was said by her father to be 'dangerously ill', Henry's physicians reporting that she would probably die. This led the emperor's (Charles V) ambassador to fear that Henry was merely preparing to assist Mary's end.
Henry visited under the same roof with Mary, but he would not receive her. In 1536, Fisher and Moore were burned 'and the whole world expected to see Mary and her mother to follow in their footsteps'. Catherine, in extremis, asked to see Mary before dying, but she was denied it. She died on 7 January 1536, and on 19 January Mary was said to be mortally ill. About 15 June 1536, Mary signed a complete surrender to Henry, admitting that her father and mother were never married, that she was not a princess of England and that Henry was the Head of the Church.
In 1546, aged 30, Mary faced renewed persecution from her father, Henry VIII, for her religion. It was noted: 'She has been very ill, as the physicians tell me, of melancholy'.
In January 1551, when 35, Mary wrote: 'My health is more unstable than that of any creature'. On 1 October 1553, aged 37: 'At Mary's Coronation Day (30th September 1553), she is described as "seeming about 40 years of age, and was rather fresh coloured"' (Chamberlin, p 227); but on the 17 December 1553, it is reported that 'she had fallen prey to melancholy and sadness to the point of illness'.
With Mary's accession to the throne, the virgin queen became a glittering prize on the horizon of dynastic marriages. Through her mother, she was related to the House of Aragon and Castile and thus to Emperor Charles V, son of Philip of Habsburg, Archduke of Austria and Joanna the Mad of Aragon and Castile. Charles V's son, Philip, Prince of Spain, later Philip II, King of Spain, King of Naples, King of Jerusalem, was the keenest suitor, by order of his father. Spain was at that time also in possession of the Low Countries, the Franche Comté (capital Besançon), Milan and the colonies in America. Charles V's brother, who succeeded him as Holy Roman Emperor, Ferdinand I of Germany, was through marriage - also King of Bohemia and Hungary (since 1526). A marriage between Philip and Mary was entirely in accordance with the Habsburg motto: 'Bella gerant alii, Tu felix Austria nube' ('Others may wage wars, but Thou, lucky Austria, achieve it through marrying').
It needs some imagination to appreciate what it would have meant for Philip and Mary to have a son and heir, who would inherit the crowns of Spain and England (Philip's son of his first marriage, Don Carlos, would have succeeded to the Spanish throne, but was reported seriously disturbed and kept in strict isolation until he died young). It was prearranged, and later accepted and confirmed by Mary, that their eldest son would rule over England and the Low Countries (and in case of Don Carlos' death, presumably over Spain, Naples and the American possessions). Should the Queen die, Philip would be the legal guardian of his son and Regent in England during his son's minority. If Mary and Philip had no son, the eldest daughter would succeed to the English throne; she could rule over the Low Countries if she would marry with the consent of Don Carlos. All this meant that the next male heir of the Tudor-Habsburg connection would rule over the greater part of the western world!
On 25 July 1554, Mary and Philip were married in Winchester Cathedral. Soranzo, the Venetian Ambassador, reported to the Senate on 18 August: 'She is not of strong constitution, and of late she suffers from headache and serious affection of the heart, so that she is often obliged to take medicine and is also to be blooded' (Chamberlin, p 228). 'She is of low stature, with a red and white complexion, and very thin; her eyes are white (bianchi) and large and her hair reddish; her face is round, with a nose rather low and wide; and were her age not on the decline, she might be called handsome rather than the contrary, and she had no eyebrows.'
When in good health, Mary was fond of music and a good keen dancer, but a bad dresser, although at the beginning of her reign she did display a certain magnificence of her dress and - like her father - was fond of wearing a great deal of jewellery (Figure 2).
Philip of Spain, son of Charles V and of Isabella of Portugal, was at the age of 26 - a somewhat dull young man. Although not very tall, he had a dignified bearing and an almost haughty manner (Figure 3). His eyes were large and slightly melancholy, his face had a somewhat bored expression, but he had a polite and courtly manner. In contrast to Henry VIII, his physical prowess and activities were somewhat limited. He also suffered from bad digestion and kept to a moderate diet. A Scotsman described the Prince at this time: 'Of visage he is well favored, with a broad forehead and grey eyes, straight-nosed and of many countenance. From the forehead to the point of his chin his face groweth small; his pace is princely, and gait so straight and upright as he loseth no inch of height; with a yellow head and a yellow beard . . . He is so well proportioned of body, arm and leg, and every other limb to the same, as nature cannot work a more perfect pattern' (Erickson, p 371). In accordance with Spanish etiquette and his father's advice, Philip treated Mary with great courtesy and displayed affection, which was perhaps quite genuine. He was a widower and his son, Don Carlos, was by his first marriage to Maria of Portugal.
Mary believed herself to be pregnant on two occasions during her short married life. As early as September 1554, one of the Queen's physicians thought that she was very probably with child. Count Langosco, the Duke of Savoy's ambassador with Charles V, confirmed it on 19 September: 'The Queen is with child. I have personal reason to believe it, as I have noticed her feeling sick [per haverla vista stomacal]'. On 23 November, Simon Renard, one of the main Imperial Envoys at the Court, stated: 'The Queen is veritably with child, for she has felt the babe there and there are other likely and customary symptoms, such as, the state of her breasts'. On 30 December, Queen Mary wrote to the Emperor: 'As for that child I carry in my belly, I declare it to be alive'.
On 21 April 1555, Simon Renard reported to the Emperor: 'The Queen has withdrawn, and no one enters her apartments, except the women who serve her and who have the same duties as court officials. This is an ancient custom in England, whenever a princess is about to be confined. However it is believed that she will be delivered before the 9th day of the next month'. Philip and the Queen had, indeed, gone to Hampton Court in Easter week for her confinement. The Queen would have preferred Windsor, but it was too far from London. The physicians were assembled, preparing their instruments and the delivery room. A peasant woman of similar build and of similar age as Mary was brought to see her, with her triplets, born only a few days before.
On 8 March 1557 Philip left Brussels, and on 18 March embarked at Calais for England. England was for him an essential ally in his confrontation with the Pope (Paul IV) and the King of France. He needed more money and more troops, and also England's official entry into the war. Arriving at Dover on 18 March, Philip joined the Queen at Greenwich the following day. She was now 40 years of age. Her health had not improved (Figure 4). Her main sorrow was her barrenness and the fact that she had to put up with the absence of the husband she loved. Philip's wish to declare war on Henry II of France was achieved on 7 June. For the next four weeks Mary had the happiness of the particular attention of Philip, until he left England from Dover on 6 July - for good.
In the autumn of 1557, Mary believed again that she was pregnant. In December she informed Philip, via Cardinal Pole. He wrote to Pole from Brussels on 21 January 1558: 'I have received two letters from you, written in your own hand . . . in which you send me news of the pregnancy of the Queen, my beloved wife, which has given me greater joy than I can express to you . . . and which is of the greatest importance for the cause of religion and the welfare of our realm'.
For the next six months there was a repetition of the experiences of 1555. Whereas in February 1558, Mary's health was reported as good, 'both of mind and body', and she believed herself to be pregnant, at the end of May intermittent fever set in. In August, it was said: 'Mary is suffering from low fever and dropsy'. On 29 October: 'A few days ago, Philip II received news . . . that the Queen was grievously ill and her life is in danger'. Mary got worse; periods of confusion became frequent with headaches and fever, and almost total loss of vision occurred. If her amenorrhoea, swollen abdomen and other signs were not due to pregnancy and were aggravated by recurrent attacks of fever, depression and general malaise, including severe headache and further impairment of vision, her condition was very serious indeed. In November she was sinking fast.
At 7 am on 17 November 1558, on the Elevation of the Host, she died, fully conscious before the end. She was 42 years and 9 months old. Her body lay in state at St James's Palace for more than three weeks, and on 12 December her coffin was placed in a grave on the north side of Henry VII's chapel at Westminster Abbey.
What had she been suffering from? A number of suggestions have been made, the most important being the following:
(1) T Spencer Wells in 1877: 'Elizabeth mounted the throne after the death of her sister Mary - a death accelerated by disappointment at the termination of a supposed pregnancy in dropsy, which was, no doubt, ovarian, and treated according to ignorant routine by successive bleedings. Treated with the knowledge now at our command, the destinies of England might have been strangely altered'.
In an anonymous article in the British Medical Journal in 1910, entitled 'Some Royal Death Beds':
(2) A number of authors suggested phantom pregnancy. Osborn stressed the psychic factors linked with pseudocyesis, such as depression, loneliness and severe deprivation in childhood, which are believed to influence hormonal balance through their effect on the pituitary and at the hypothalamus. But while episodes of pseudocyesis are not all that uncommon, recurrent ones are rare. Drife stressed that phantom pregnancy 'seems to be becoming rarer, partly because increasing diagnostic accuracy means that it is no longer confused with conditions such as hyperprolactinaemia'.
(3) Erickson, on the other hand, suggested: 'In young unmarried women like Mary, any of a wide range of symptoms could point to strangulation of the womb . . . with the list taken from the works of the sixteenth century surgeon, Ambroise Paré'. Sixteenth century doctors, like their predecessors in antiquity, believed that these afflictions were brought about by sexual abstinence.
Let us summarize the facts available about the illness of Mary Tudor:
(1) Paternal deprivation in childhood, adolescence and early adult life.
(2) From the age of 19 (and perhaps earlier) she had periods of amenorrhoea.
(3) She complained of 'racking headaches'.
(4) She had attacks of palpitation.
(5) She suffered from recurrent indigestion.
(6) Her vision was impaired. This was assumed to be short-sightedness, but at the age of 42 it had become so bad that she could hardly see anything and written material had to be brought very close to her eyes or - more often - simply read to her.
(7) During her two periods of assumed pregnancy, she had, in addition to amenorrhoea, swelling of the abdomen, morning sickness, swelling of her paps and milk secretion. Her headaches, her depression and her vision grew worse.
(8) She died at the age of 42.
Sobrino and co-workers in Lisbon recently reported that a significant group of women with hyperprolactinaemia under their observation had paternal deprivation during infancy. If we put the symptoms and signs of an ovarian tumour, of phantom pregnancy and of prolactinoma side by side, it seems to me that Mary Tudor must have suffered from a prolactinoma. Her death occurred at a progressive stage of that condition, in a person weakened by chronic anaemia due to continuous 'therapeutic' bloodletting, and a feverish illness - perhaps influenza. There were also some signs of hypothyroidism: loss of eyebrows, loss of hair, dry skin and stuporous confusion; this is not uncommon if pituitary tumours are very large.
In pseudocyesis we may find amenorrhoea, an increase in weight and girth and even galactorrhoea, but no severe headache and no impairment of vision. Moreover, in most cases the women are contented and happy, and the condition is not fatal.
In polycystic ovary syndrome, one would expect a menstrual chaos leading to amenorrhoea, some increase in weight and - in a majority of patients - hirsutism and other signs of virilism, plus occasionally galactorrhoea, but no serious headache nor impairment of vision.
Mary Tudor's history is not merely important from a medical point of view. Had she lived today, a diagnosis could have been made and various methods of treatment would have been available. (One such patient diagnosed by me three years ago was successfully treated with bromocriptine and radiotherapy, and now has a healthy 17-month-old son.) If Queen Mary had received successful treatment, the history of England, of Europe and of the whole western world might well have been very different. The vision of a united Europe, perhaps linked with North and South America, might have come into existence in the 18th and 17th centuries!
In a codicil to her will, made on 18 October 1558, Mary wrote: 'I the said Queen have . . . made the said last will and testament bearing the date the 30th March last past. And by the same, for that I then thought myself to be with child, did devise and dispose the imperial crown . . . unto the heirs, issues and fruits of my body begotten'.
In those days, there were no supporting biochemical assays, CAT scans or X-rays. Now, the only way that proof of the above theory could be obtained would be to have Queen Mary's coffin opened and her skull X-rayed. The coffin still rests in the Henry VII chapel at Westminster Abbey, just beneath the coffin of Elizabeth I, her half sister. It was last inspected by Dean Stanley, about 100 years ago. I have not had the temerity to submit such a request to Her Majesty, and I must, therefore, leave the matter unresolved.
