Some Epidemics of Social Importance
There is some reason to believe that Hippocrates himself, our professional father, who drew up that oath by which all modern doctors measure their conduct, knew the bubonic plague when he saw it, though he never went through a plague epidemic. The first epidemic of which we have detailed knowledge is the great plague of Athens in the Peloponnesian War about which there can be very little doubt, for it was described by one of the greatest literary artists of Greece, who saw it all with his own eyes, and suffered from it. Thucydides was not a doctor, but like Cervantes he had the eye and mind of a doctor; and he could describe a disease so plainly that many other ancient and even mediæval historians have taken their descriptions of their own epidemics straight from his with never an acknowledgment. And in Thucydides’ account of that plague we get the invariable conditions of all epidemics—the ungovernable terror of the people, the powerlessness of the doctors, the abandonment of all moral laws, the wild accusations of poisoning by enemies, the selfishness, cowardice, and ignorance of man in a panic, the hysterical dancing in the shadow of the tomb. From this one learn all.
I give a translation of Thucydides’ description of the symptoms, by C. Foster Smith. It must be remembered that Athens was being besieged and the Athenians had brought all the farmers into Athens so that the Spartans should find no food for the Lacedæmonian armies; the device of an already beaten nation.
“The disease began in Ethiopia and then descended into Egypt and Libia. Then it suddenly fell upon the Piræus and city of Athens, so that people at first said that the Peloponnesians had put poison into the cisterns. Afterwards it reached the upper city also, and from that time the mortality became greater. I have had the disease myself and seen others sick of it. Suddenly men were seized first with an intense heat of the head and redness and inflammation of the eyes, and the parts inside the mouth became bloodshot and exhaled an unnatural and fœtid breath. In the next stage sneezing and hoarseness came on and in a short time the disorder descended to the chest attended by severe coughing and sneezing. There was severe vomiting of every kind attended by great distress; and in most cases ineffectual retching producing violent convulsions which sometimes abated directly, sometimes not very long afterwards. The body was not very hot to the touch; it was not pale, but reddish, livid, and breaking out into small blisters and ulcers. Patients could not bear to have on them the slightest covering or linen sheets, but wanted to be quite uncovered and would have liked best to throw themselves into cold water—indeed, many who were not prevented did so. Most of them died on the seventh or ninth day from internal heat, but had still some strength left. After the crisis the disease sometimes attacked the privates and fingers and toes, so that many patients lost these, though some lost the eyes also. Immediately after recovery there was often loss of memory, so that many failed to remember either themselves or their friends. The most dreadful thing was the despondency of the victims.”
I am glad to say that I personally did not serve in the Balkan campaigns, but many doctors who did tell me that Thucydides’ description might, with a little imagination, be stretched to include that plague which proved so distressing to Dr. Elsie Inglis and her gallant band. In other words, Thucydides was describing typhus fever, which has always been the enemy of besieged cities, especially in hot and dirty surroundings. Dr. Crawfurd states that we may look upon it as almost certain that the plague of Athens was typhus fever, though he discusses at considerable length the academic question whether it might not have been bubonic plague or smallpox. At least we can say for certain that the plague of Athens showed more of the symptoms of typhus fever than of any other known disease; and if Dr. Crawfurd is wrong he had made a very shrewd guess. From my own experience of typhus, which is small, I should certainly be inclined to support him. But typhus nowadays is a thing almost of the past except in times of war. That we owe simply to washing ourselves and our clothes better than of old. It is a remarkable thing in clinical experience that typhus frequently accompanies bubonic plague, because they are both diseases of primitive civilisations like India and China to-day.
Passing over the innumerable ancient attacks of pestilence upon mankind, we come to the great plague of the Antonines which was probably the real cause of the decline and fall of the Roman Empire, for it is extremely doubtful whether the Empire ever recovered from it. To most of us this plague is remarkable for the fact that Galen, the Roman Hippocrates, ran away from it, and has left us an account of it which seems to have been drawn second-hand from Thucydides. In the Roman Empire many of the physicians were Greek slaves and had the slave mind. Though Galen himself was not a slave, still he was a man of his time, and it was not then thought imperative that a doctor should, in Dr. Crawfurd’s words, be “captain of his soul.”[17] Dr. Crawfurd gives many instances of honoured names whose owners ran before the onset of plague; and it was not till the Black Death that we find the real true silent courage that we now expect from the medical profession as a matter of course.
The plague of the Antonines seems to have varied in different parts of the Empire and at different times of its devastating career.[18] Occasionally it seems to have taken the appearance of smallpox, sometimes of typhus, and perhaps at times an infusion of bubonic plague may have thrust in its frightful form. It would be much easier for after generations to guess at the truth if only poor Galen had not taken wing and fled; for he was an acute clinician. At its first onset he fled to Campania and, finding no safety there, took ship to Pergamos. Thence, after two years’ absence, he returned at the urgent summons of the emperor, Marcus Aurelius Antoninus, and after a brief stay in Rome rejoined him again at Aquileia. But there was no rest for his weary soul; again pestilence pursued him. The thing would be comic if we could forget the frightful misery of mankind when the foundations of civilisation were crumbling before the assaults of micro-organisms. Man was engaged in one of his greatest battles to the death against the wild; and the rat, the body-louse, and the direct infection of smallpox were apparently leagued in an assault upon his works. It is a dramatic thing to stand before the great statue of Marcus Aurelius at the head of the Capitoline steps in Rome, near the smell of the caged wolves, and to ponder that the real enemy of that somewhat tedious emperor was, not the Quadi or the Marcomanni, but, unknown to himself, if Dr. Crawfurd is right, the ignoble body-louse and the squeaking, fighting, greedy Mus Decumanus.[19] And yet he sits there so proudly upon his wonderful horse, looking every inch an emperor yet unable to cast even a moral maxim at his ignoble foes.
After the plague of the Antonines we come to the great plague of Justinian and here at last we have the evidence of an exact historian who did not run and could state what he saw in language that we can understand. Gibbon says hesitantly that Procopius was a doctor, though probably in truth he was a lawyer. Possibly he was too much afraid of the naughty little Empress Theodora, whom he was afterwards to slander, to forsake the path of duty and run away when the world seemed dying; but at any rate he has left us a remarkable account of the plague of 542, one of the most terrible recorded visitations of epidemic disease; and after reading Gibbon’s somewhat excitable account of it I think that few doctors will deny that it was real old bubonic plague that has so often made history. Justinian suffered from it and recovered; we do not know enough about the exact circumstances to estimate its exact effects upon the world; but we can be pretty certain that the bacillus pestis did not lay waste the Byzantine Empire for nothing. Gibbon estimates the total loss of life at a hundred millions; but one doubts if the population of the Roman Empire, even in its palmiest days, was ever much larger, and surely the plague could not have swept off everybody in the known world, though we do know that, if it really breaks loose in flea-bitten surroundings, plague can do an infinity of mischief, probably more than any other known disease.
We leave the dead old world that shook at Cæsar’s nod, and leap in one moment to the very beginnings of the modern world, to the Black Death of 1348; for, though the Middle Ages were still to drag their slow length along for at least a century, there can be little doubt that after the Black Death had terrified mankind all our modern problems were beginning, if only in embryo. The original source of it seems to have been China, and the epidemic proceeded with most leisurely footsteps until it took ship for Europe. Dr. Hecker[20] in 1833 wrote an exhaustive account of it from mediæval records; but since 1833 the cell-theory of Schleiden and Schwann has revolutionised medicine, and even Dr. Hecker has to be translated into modern terminology; so rapidly has medicine changed that a book written ten years ago is already obsolete. Indeed, it is not too much to say that more has been discovered in medicine within the last thirty years than in the whole previous half-million years during which man has been upon the earth; one sometimes becomes terrified at the amazing growth of knowledge. Whither is it all leading us? Are we becoming as gods? Vespasian joked about himself when he was dying; let us not really grow “pumpkinified,” to use Seneca’s words about Claudius, when we think ourselves becoming deified.
The Black Death seems to have come to Europe from Africa by ship in 1348. The harbingers of the epidemic began in 1347 with earthquakes and floods in China and Egypt; in far-away China the earth opened and swallowed men. Frightful portents appeared in the sky (of course I am simply quoting this nonsense from Hecker and his mediævalists) and the seasons changed, summer becoming winter. At that time, according to Hecker, the sheet of ice was formed which has since prevented men from looking upon the coast of Greenland; there were unequalled rains and the floodgates of heaven were opened in a more than Noachian deluge. Vast swarms of locusts appeared and died; and the want of the crops which they had devoured thrust man, whose hold upon the earth is always so feeble, to the edge of that slight precipice which generally protects him from the Valley of Starvation. The earth opened, and into the crevasses men fell, never to be seen again; from the crevasses arose a horrid stench. Into this world, even more starved and terrified by the adventure of living than was common in the Middle Ages, the rat and the bacillus pestis made their death-dealing plunge. The epidemic which they brought seems to have been carried from the sultry delta of the Nile by ship to Greece and Italy; four fugitives—and unknown numbers of rats and fleas—fled to find safety in Marseilles, carrying their own destruction with them. Thence the plague went to Avignon, at that time the residence of the pope; and ultimately to England where it landed in the southwest counties, taking half a year to crawl to London. As acutely noted by Procopius, plague always spreads inland from the shores of the sea, and we now know that it spreads just so fast as the rat can run and no faster. In 1348 they knew nothing about rats and bacteria, but attributed everything to bad air or evil spirits; and they noted that there was a continuance of southerly winds, which of course in Greece and Italy are hot winds and may possibly have spread the plague by bringing the ships and their contained rats. In Germany they had some story about a dense pestiferous fog which smelt abominably and so was obviously the cause of the Black Death. It is difficult to say how much truth there was in these stories of fog, though they are too numerous and too well attested to be utterly ignored; they have naturally been seized upon by historical novelists in search of the dramatic and anxious to show that in 1348 everything was different from things as they are to-day. Possibly they accounted for the preponderance of pneumonic plague.
John Cantacuzenos, Byzantine emperor, whose own son died of it, left a description that entirely fits in with our modern knowledge of plague, buboes, black spots and all, though there is a certain resemblance to Thucydides which makes one rather believe that he was adding to his narrative for dramatic effect. Strangely modern is his description of the dull stupor that affects so many plague patients to-day. We all noticed it in the slight epidemic that affected Sydney some years ago. Then again John specially stated that some patients were attacked by a violent pain in the chest, with difficulty of breathing and a putrid expectoration. This looks uncommonly like the pneumonic type of plague which proved so destructive in Manchuria in 1910.
But the most interesting feature of the Black Death was its attack upon Avignon, where Guy de Chauliac was physician to the pope. It lasted eight months, with the usual concomitants of numbers of dead so huge that the living could not bury them. As trench after trench became filled, no matter how hard the living worked, the pope blessed the Rhone and had the bodies hurled into that rushing stream, doubtless to the joy of the rats. Guy himself showed the courage that one expects in a modern doctor, and has left us a perfectly recognisable description, which is commented upon by both Dr. Hecker and Dr. Crawfurd. It is in Guy himself that our interest dwells; for at last Medicine had found its soul. His colleagues, being trained in Arabian medicine, all told him that the plague was inevitably fatal, that medicine could do nothing, and that he was only courting destruction by staying to comfort those whom he knew that he could not save. Guy himself had a theory that strong purgation would cure the disease, though he knew that the only real safety was in flight. He stayed; though whether he was prevented from running by the medicines that he prescribed or by sheer courage no one can say. His own words were “As for me I did not dare absent myself, though I was in constant fear.” To be feared of a thing and yet to do it—that is what makes the prettiest kind of a man; and to be afraid only of his own conscience makes a man a hero. Guy was afraid of his own conscience, not of the plague, and therefore he has become one of the heroes of medicine. No doubt he donned his quaint mediæval anti-infection costume with its beaky vizor, and went from door to door trying to bring a little hope to the gloomy death-beds of the frightened people; no doubt he had himself to clean up the mess caused by his treatment, which must have been calamitous. But he lives in the memory of his colleagues, for we are all proud to belong to the profession of that simple-minded doctor of Provence, and try to act like him though with less messy treatment. He was a brave man.
The epidemic endured at Avignon for eight months, and Guy tells us that for the first three it took the form, in our terminology, of pneumonic plague and was intensely infectious, but for the other five it seems to have been the ordinary bubonic that was so fatal in London in 1665. Guy remained in Avignon for the Black Death, and faced its return twelve years later. In the first visitation the poor suffered, but in the second the rich; but, rich or poor, Guy remained at his post with his ample store of aloes to win the love of the dying whom he could not save. We know now some results of crude aloes which are not very pleasant, and I wonder whether Master Guy de Chauliac ever noticed them, or whether his patients ever came running to him to cure them of the effects of his aloes.
To sum up, it is probable that the series of epidemics that we call the Black Death were all different varieties of the plague; bubonic, pneumonic, septicæmic, hæmorrhagic, etc. The sentimental and journalistic Nordic nations, such as the English and Germans, muttered the horrified name “Black Death,” afraid to give the thing a name, just as to-day they talk about the “Red Plague” or “a certain loathsome disease” when they mean to say syphilis; but the more clear-sighted and logical Mediterranean peoples knew that the thing certainly killed them, though they did not know what it was, so they simply called it La Grande Mortelaga—the Great Mortality, which it assuredly was. We prosaic moderns simply call it the plague, whose dread name even to-day makes us shudder. We do not fear it, because we know exactly how it is spread, and that, to use Osler’s epigrammatic words, all that one needs to defeat an epidemic of plague is a stout heart and a long purse. During the fourteenth century men’s hearts, being very ignorant, were not very stout, and their purses were atrociously short. It would hardly be too much to say that during the Middle Ages, and up till about 1700, the greatest cause of death in cities was the plague. After 1700 people slowly began to become rich, and to build better houses which would keep the rat at a distance, so that man conquered the plague without knowing how he had done it. But the conditions in the Middle Ages must have been frightful. Listen to the words of Dr. Abram in English Life and Manners in the Later Middle Ages about the overcrowding, which would put even Glasgow to shame. He is referring to the Miller of Trumpington in Chaucer’s Reve’s Tale; and the miller cannot have been a very poor man; he was prosperous and on edge for his dignity. But in his house there was only one bedroom, where slept he himself, his wife, his baby, his grown-up daughter, and two undergraduates from Cambridge all at once.
No wonder the rats and fleas were rampant and the plague swept over the land. And as for the personal cleanliness of these crowded peoples, there was none.[21] If I wished to use another jargon than medical I would say it was a minus quantity, but personally I prefer the medical, because that means something and is exact.
The Black Death revived that strange and mournful sect of the flagellants, the Brotherhood of the Cross. The spirit of man, which is capable of such wonders, must needs bow before that shadow of itself which it has projected into the infinite, and ask pardon of its anthropomorphic fourteenth-century God for the fancied sins which had brought these horrors upon the world. The quaint figures of the flagellants wandered, cross on breast, in doleful procession all over Europe, chanting dolorous hymns of misery that bore the seeds of rebellion against that very God whom they affected to supplicate. They would reach a church, lie down in circles, strip off their clothing and flog each other with scourges of nails. People crowded to watch the blood flow, while doubtless the rats and fleas rejoiced if rejoicing be possible to beings so lowly. In these flagellants probably lay the real seeds of the Reformation which was to come. They sometimes seized upon a church and rebelliously conducted Mass without an authorised priest, although the pope, Clement VI, who was a brave man and faced the plague like a hero, had given absolution in advance to every patient who should be taken sick. Man wanted his own priest, and sometimes when he sent in his last extremity his priest would not come, or was dead of the plague, so that when the epidemic had abated, and the world was struggling to recover itself and reap the neglected harvests, men were only too ready to believe the stories about the priests and their women which were even then paving the way for the Reformation. The Statute of Labourers, in England, was the herald of many of our modern political ideas. Those unhappy men who died, stupefied by plague, were really dying for humanity.
We cannot make an accurate guess even at the actual number of people lost during the Great Mortality. Hecker, after taking the utmost trouble, thought that at least a fourth of the people of Europe perished, but in some places far more; thus in Avignon, of which we have the most exact information, about nine-tenths. This vast mortality in Avignon was not caused by de Chauliac and his aloes, any more than it was due to Pope Clement and his blessing. Probably de Chauliac’s treatment had no influence one way or the other; neither did the question of pope and anti-pope nor the great schism. But we know more about what happened at Avignon than anywhere else, because de Chauliac was a brave doctor who told the truth.
We do not forget the plague, because it takes very good care of that, and is still, though we have long purses, the nightmare of health officials who keep their silent watch over the health of mankind.
But, in dealing with epidemic diseases that have affected civilisation we must not forget malaria. Like syphilis itself, its social effects have been prodigious. Malaria was undoubtedly, with typhus and possibly smallpox, one of the real causes of the fall of the Roman Empire. The work of Sir Ronald Ross in discovering that it is spread by the anopheles mosquito, is one of the great epoch-making discoveries of history. There are few countries in the world which are free from malaria to-day. Unquestionably it is the cause of the anæmia and poor physique of the inhabitants of most tropical countries; and Australia is fortunate in having so few anopheles mosquitoes, though we have so many other varieties of the abominable little pests. That the numerous returned soldiers who were infected with malaria in Palestine have comparatively rarely spread their disease is due to the rarity of the anopheles in Australia; but doctors are always on the lookout for this particular pest and let us hope will keep it to its natural habitat in moister countries. Probably the real reason of the good physique of Australians is that the British race, for the first time in history, has had the chance of developing in a warm climate with no malaria. We are making a mistake in concentrating on the search for the discovery of the will-o’-the-wisp cause of cancer, which, though a very terrible and horrible disease, possibly associated into the very mystery of life itself, has probably less important social effects than either syphilis or malaria. I do not merely refer to the actual death-rate from these diseases, though it is probable that syphilis indirectly causes more deaths than cancer, tuberculosis or overeating. The trouble is that syphilis works in so mysterious a way; it is sly and subtle in its effects; it lies long latent and springs up again to the slaughter after the man who is its victim has long forgotten that he ever had it; and it conceals itself under innumerable guises. The great problem before the civilised world to-day is not the cure of cancer; it is the prevention of syphilis.
We know exactly how to prevent syphilis in the male. Metchnikoff and Calmette have shown us by experimental proof that is irrefragable. That their method is impossible to apply satisfactorily in the female owing to anatomical reasons is no reason whatever for so solemnly concealing its existence from young men, because, if it were generally known to the male, the females would not be affected and the contagiousness of the disease would die out in one generation. It is painful to think of the vast mortality and misery that is caused by this one disease when every decent doctor knows exactly how to prevent it. With moral education in self-restraint together with application of Metchnikoff’s discoveries, which are known to every doctor, there is no reason whatever why syphilis should not be entirely abolished from the educated world. The other venereal diseases though serious are of comparatively minor importance; even gonorrhœa, which sterilises so many women and blinds so many babies, is less important because it does not affect the brain.
My own opinion is, that while moral education should certainly be attended to, every boy should have a quiet talk with his doctor before he goes to boarding-school and still better perhaps before he goes to the university. It is common experience that more lads become infected while they are young and ignorant, during the time of their university life, than at any other time.
We have apparently got over our post-war epidemic of influenza, which sensationally minded people called the Black Death without knowing what they said. But has fate altogether done with us? Has the war really left no other sequel than the influenza? Only this morning I was reading an article by Mr. Stephen Graham in the Nineteenth Century and After, in which he refers to the frightful post-war corruption of women in London, as shown by the mad competition among prostitutes for the favours of men. I can corroborate that article fully, for last year I went travelling over many parts of Europe, and I was impressed and horrified by exactly the same thing. A man cannot leave his hotel unaccompanied without being set upon by these women, who are evidently starving and desperate. London, Paris, and Rome are all the same; there is nothing to choose between them.
Nothing seems to be done about this frightful menace. Let us take care lest a rival to the Black Death may ruin the people of Europe. Immorality must be paid for somehow; and it does no good for politicians to wrangle over trifles such as the German restitutions when there is a very much more dreadful menace knocking at the world’s doors.
During Tudor times, when the world seems to have been almost at its lowest stage of filth, there were great epidemics of typhus fever in Europe, especially in Italy; thus reviving memories of Athens and the Roman Empire, which to the eyes of modern men seem to have been an age of beauty. Typhus is beyond all other diseases the disease of filth, war, and misery; and that it spread so vigorously in the fifteenth and sixteenth centuries seems to show that things at that time were less romantic than people try to depict. Probably, if we could get at the real truth, throughout recorded history, typhus has slain more people than any other epidemic disease, possibly even more than the plague itself.
There can be little doubt as to the identity of the “Sweating Sickness” of Tudor times. It seems to have begun with the bloodshed of the Wars of the Roses, as the army of Henry VII marched in misery, slush, and triumph after the battle of Bosworth. Very soon after the king’s entry into London the sweating sickness began to spread among the overcrowded houses of the capital. It ravaged high and low; at first it spread largely among young and vigorous men; in one week it took two lord mayors and six aldermen. The coronation of Henry VII was postponed by reason of the general distress, and the disease spread without interruption over the whole country. Nobody seemed to be immune; and when it attacked Oxford the professors and students fled alike in a common terror, so that the ancient university was as deserted as it was, for a more worthy reason, during our late war.
After its first appearance, sudden and savage, the English Sweat for a time abandoned its victims, and the mediæval world resigned itself to its normal accompaniments of epidemic typhus, smallpox, and plague. Soon after the return of Columbus we begin to hear of a new and terrible disease, syphilis,[22] though there has been great argument as to whether it may not have been yaws, which is a comparatively mild tropical long-continued ailment. To my mind the fact is convincing that we find no real traces of syphilis in the bones from ancient burial-places. If it had existed in the ancient world we should certainly have found such evidences.
But the English Sweat was only biding its opportunity; for it returned mildly in 1506; and again severely in 1517; and again, in its worst epidemic, in 1528. By this time the world was beginning to think that we were eternally damned; and when in 1529, it spread to Hamburg, the good North Germans tried to signify their belief in the usual manner by confining their patients in the best replica of hell that they could imagine. Every patient, whatever his sickness, was hidden under a heap of featherbeds; the stove was driven to its full force; the windows shut and sealed with rags; and the patient’s relatives heaped themselves upon him until it sometimes happened that he was actually smothered by their well-meant efforts.
Besides the sweat, influenza recurred again and again; and slew its thousands and tens of thousands. It probably so weakened Mary Tudor’s heart that she died suddenly while hearing Mass.
Now what was this dreadful Sweating Sickness which so paralysed over and over again the strong arm of the Tudors? Osler describes it confidently as what we call miliary fever; a disease which now and then breaks out in little valleys of Italy and Eastern Europe; kills a few harmless people; and suddenly departs as quickly as it came.
Of course there must always be doubt as to all these mediæval epidemics. One symptom may impress one doctor as due to one special disease, another symptom may impress another as the most important. Thus, thinking of the plague of Athens, what impressed me most was the fact that Thucydides expressly mentioned the fact that the patient’s fingers and genitals used sometimes to drop off when he seemed on the high road to recovery. We see just the same symptom in epidemic typhus to-day.
It is difficult exactly to understand ancient pathological terms; when an ancient observer says “peticula” or “bubo” or “macula” or uses other learned terms, we cannot be quite sure that he means to convey exactly the same idea as the words imply to ourselves. There is always room for honest difference of opinion. But after carefully reviewing the diseases of old I fancy most people will agree with Sydney Smith when he wrote:
“The good of olden times let others state.
I think it lucky I was born so late.”
With all the glamour that enthusiasts and romanticists have cast upon the Middle Ages we are probably very much happier to-day.