The Epidemics of the Middle Ages

by J. F. C. Hecker; John Caius

A striking resemblance is plainly perceived, from this description, between the ancient cardiac disease and the English Sweating Sickness in the most exquisite cases of each. In both the same palpitation of the heart, the same alteration of the voice, the same anxiety, the same impediment to respiration, and thence the same affection of the nerves of the chest, the same ill-scented sweat, and, by means of this sweat, the same fatal evacuation; in short, all the essential symptoms arising from the same circle of functions. For in the sweating pestilences of the ancients[479], as well as the moderns, the nerves of the abdomen remained unaffected; the liver, intestines, and kidneys, took no part in the primary affection; the diaphragm, as in the English Sweating Sickness, formed the partition. Hence the acute Aretæus did not hesitate to call the cardiac disease fainting (syncope), with certainly an unusual extension of the notion implied by this term, which in its common acceptation excludes the turbulent commotion of the heart. In the affection of the brain some difference occurs, for though the hallucination afforded an unfavourable prognostic in both diseases, yet the fatal stupor was peculiar to the English Sweating Sickness, no observer having made mention of it in the cardiac disease.

Greater and altogether essential differences between this affection and the English Sweating Sickness appear in another respect. There is every reason to suppose that the cardiac disease first appeared in the time of Alexander the Great, that is to say, at the end of the fourth century before Christ; for the Hippocratic physicians were unacquainted with it, Erasistratus, who was body physician to Seleucus Nicator, and was a universally celebrated professor at Alexandria under the first Ptolemy, being the first to mention it. If that age be compared even superficially with that of Henry the VIIth and Henry the VIIIth; and Africa, Asia Minor, and the South of Europe with England, we shall easily be convinced that the two diseases, notwithstanding the agreement in their main symptoms, could not be the same; moreover, much was comprehended by the ancients under the name of morbus cardiacus, which, on a nearer examination, proves not to be one and the same definite form of morbid action: for sometimes this affection is spoken of as an independent disease; sometimes it is mentioned only as a symptom superadded to others—as a kind of transition from other very various diseases, such as has occurred in modern times. Soranus mentions, as such diseases, continued fevers, accompanied by much heat[480]; and reckons among them the “Causus,” that is, an inflammatory bilious fever, to which Aretæus also saw the cardiac disease superadded. These fevers passed, on the fifth or sixth day, into the cardiac disease, and such a transition occurred chiefly on the critical days[481]. In a similar sense Celsus speaks even of Phrenitis, under which name we are here to understand all inflammatory fevers accompanied by violent delirium, with the exception of actual inflammation of the brain. Thus we see that the cardiac disease arose and increased on a very different soil from other diseases, and was, to furnish an ancient example, as far from being independent under these circumstances as lethargy was in similar cases.

But there was doubtless an independent idiopathic form of the cardiac disease. Whether this was febrile or not, the most celebrated physicians of ancient times were not agreed. Now, how could they ever have differed upon the subject, if the cardiac disease had always appeared only as a sequela on the fifth or sixth day of inflammatory fevers? Apollophanes, a disciple of Erasistratus, and physician to Antiochus the First, considered it, with his master, as constantly febrile, and his opinion prevailed for a long time: perhaps he was in the right, for it is probable that in the first half of the third century, the disorder was much more violent than at a subsequent period. His celebrated contemporary, Demetrius of Apamea, disciple of Herophilus, affirmed, that he had recognised fever only in the beginning of the disease, and that it disappeared in its further progress. Very soon, most physicians decided that it was not febrile, but Asclepiades distinguished a febrile and a non-febrile form of the cardiac disease, and it is certain that this physician was a very accurate observer. Themison and Thessalus also agreed with him. Aretæus described, in a cursory manner, the febrile form only, and perhaps was not acquainted with any other. Soranus followed, in the essential points, Asclepiades, the founder of his school; and later writers generally regarded the inward heat, the hot breath, and the burning thirst—symptoms which were occasionally less marked, as proofs of the febrile nature of the disease. Numerous theoretical views, belonging to particular schools, of which we do not here treat, were intermingled with these, and upon the whole, that form seems to have been esteemed as non-febrile, in which the signs of feverish excitement appeared less marked. In all cases the cardiac disease set in with external coldness, and with a small contracted quick pulse, symptoms which with certainty indicate fever[482].

Respecting the course of the cardiac disease, we are not furnished with sufficient information. It was no doubt very rapid, for the frame could not long endure symptoms of so violent a kind, and the disorder must of necessity soon have come to a crisis; yet from the ample directions for treatment, we may conclude that it lasted at least some days. If the perspiration was well surmounted, patients seemed to recover rapidly, and their sufferings appeared to them, according to the expressions of Aretæus, like a dream, out of which they awoke to a consciousness of the increased acumen of their senses[483]. But the termination was not always so fortunate. The disease was very dangerous, and in many, after the occurrence of an incomplete crisis, an insidious fever remained behind, which ended in a consumption[484]. The whole phenomenon was altogether peculiar, and among existing diseases there are none which bear any comparison with it.

There must therefore have been something in the whole state of existence among the ancients which favoured the formation of the cardiac disease. That it arose oftener in summer than in winter, that it attacked men more frequently than women, and especially young people full of life, and hot-blooded plethoric persons, who used much bodily exercise, we learn from credible observers[485]. In this respect, therefore, it bore a resemblance to the English Sweating Sickness. We may also add, that indigestion, repletion, drunkenness, as likewise grief and fear, but especially vomiting and the employment of the bath after dinner, occasioned an attack of the malady[486]. Let us call to mind the habits of the ancients. It was in the time of Alexander that oriental luxury was first introduced. Gluttony became a part of the enjoyment of life, and warm baths a necessary refinement in sensuality, which just at this time were philosophically established by Epicurus; nor was this the last instance in which philosophers encouraged the errors and infirmities of human society.

Here, again, therefore, as in the English Sweating Sickness, we meet with the relaxed state of skin, and the foul repletion engendered by the same indulgence in sensuality which we have found to exist in the sixteenth century. How this corruption of morals increased, and to what a frightful height it was carried among the Romans, it is not necessary here further to elucidate; and we may take it for a fact, that in consequence of it, the general constitution of the ancients underwent a peculiar modification; that this relaxation of skin and gross repletion were propagated from generation to generation; and that, as among chronic diseases, those of a gouty character were its more frequent results, so among the inflammatory, the cardiac disease made its appearance as the general effect of this kind of life.

Where, however, such a system of life existed among whole communities, the original and peculiar occasion was not needed in every individual case to bring the predisposition for a disease which propagated itself by hereditary taint, to an actual eruption. Shocks to the constitution of quite a different kind were often sufficient for the purpose. Thus, among the Romans, it was by no means always the case, that gluttony and relaxation of the skin immediately gave rise to the cardiac disease; while, on the other hand, the usual faintness, induced by too copious blood-letting, passed into this impetuous agitation of the heart, accompanied by colliquative sweats[487]; and all overviolent perspirations in other diseases were apt to take the same dangerous course[488]. We must here also take into account a practice among the Romans, which was very injurious, and yet rendered sacred by the laws; namely, visiting the public baths late in the evening, just after the principal meal, and awaiting the digestion of their food in these places of soft indulgence[489]. How much must the tendency of sweating disorders have been favoured by these means!

Surmises founded on the facts already stated, can alone be offered respecting the nature of the ancient cardiac disease. The ancients give us no certain intelligence upon it; for their mode of observing did not lead to that object at which modern medicine aims. That the cardiac disease was not of a rheumatic character seems deducible from several circumstances—from the quality of the atmosphere in southern climates, which is not so favourable to rheumatic maladies, as to give rise to a distinctly defined form of that complaint throughout a period of five hundred years; from the nature of the so-called inflammatory fever, which exhibited no rheumatic symptoms in its course; and lastly, from the treatment of the cardiac disease, for it was a common practice to cool down the “diaphoretic” patients in the midst of their perspiration, by sponging them with cold water, to expose them to the air, and some physicians went so far as to advise cold baths and affusions[490]. How could they have ventured upon such remedies if the cardiac disease had been of a rheumatic nature?

In the sweating fevers of the sixteenth century, every abrupt refrigeration, every exposure of the skin, was fatal. It is thence to be inferred, that the English Sweating Sickness differed from the ancient cardiac disease in its rheumatic character; even although both diseases were founded in common on an impure gross repletion and relaxation of skin, and the essential phenomena of both went through the same course: not to advert to other differences which are manifest from what has been stated.

The remaining treatment of the cardiac disorder should not be altogether passed over in this place, because it shews very clearly the general style of thinking of the medical profession, as also certain metaphysical excitations which are innate in that profession, and of which there is therefore a repetition in all ages. For whilst some proceeded with commendable care and caution, and Aræteus feared[491] a fatal result from the slightest error, others again, would fain render excited nature obedient to their rough command by means of the most violent remedies. It, therefore, occasionally happened that in their over hasty activity they were unable to distinguish between a salutary perspiration and a dangerous “diaphoresis.” This they suppressed at all hazards, and thus sent their patients to the shades of their fathers. Others forthwith flew to Chrysippic bandaging, the great means of suppressing profuse evacuations, and even violent spasms[492]. Others were for obviating the debility as quickly as possible by means of nourishing diet; and overloaded the stomach, as if the recovery of strength depended entirely upon eating. Others allowed as much wine as possible to be drunk for twenty-four hours together, even to the extent of producing intoxication[493]; and Asclepiades selected for this extraordinary death-bed carousal the Greek salt wine[494], for the sake of bringing on a diarrhœa, whereby the opened pores of the skin might again close, and the too mobile atoms might be carried towards the bowels. With the same object he ordered active clysters[495], for if they succeeded in causing a full evacuation, he maintained that the perspiration must necessarily be arrested! Endemus, of the Methodic sect, recommended even clysters of cold water[496], and whatever else the rashness of medical men had fool-hardily contrived; acting on the ancient notion, that severe diseases always required violent remedies. Aretæus recommended blood-letting, which others pronounced to be nothing short of certain death[497]. He had, however, a notion that the Causus was the foundation of the cardiac disease, and perhaps he was right.