Plague and pestilence in literature and art

by Sir Raymond Henry Payne Crawfurd

There is scarcely a single writer of the sixteenth, seventeenth, or eighteenth centuries on the subject of fevers, who has not commented on the concurrence of malignant fevers with epidemics of Oriental plague. It is true that they do not all identify the malignant fevers as typhus, simply because typhus, though distinguished as a morbid entity by Fracastorius as early as 1546, did not become generally recognized throughout Europe until the eighteenth century, and even then its identity was obscured under a multiplicity of synonyms. Ambroise Paré, in 1568, described a pestilential fever as prevailing in France along with true plague, in which the skin was marked with spots, like the bites of fleas or bugs. Vilalba says that on several occasions during the sixteenth century a spotted fever called Tabardiglio, which is now known to have been typhus, was rife in Spain at the same time as plague, and was much confused with it. According to Lotz a malignant spotted fever was present in London in 1624, which turned to plague in 1625, and back again to spotted fever in 1626. Similarly Sydenham states that the Great Plague of London was preceded and followed by a pestilent fever, which from his description was clearly typhus, and he remarks that it differed from the plague only in the milder character of its symptoms. According to Diemerbroeck spotted fever (typhus) preceded plague in Holland in 1636, and its malignity increased progressively, until finally it became converted into true plague. The same is true of the [plague of Marseilles] in 1720, of the plague of Aleppo in 1760, and of the plague of Moscow in 1771. Hancock, in 1821, asserted that nearly all the most remarkable plagues of the last two centuries had been preceded by typhus. So much for the confusion of these two diseases, due to their concurrence.

Murchison, whose treatise on typhus stands out as a monument of acute and accurate observation, traces out in detail the resemblance of the two diseases. It is no matter only of a general clinical resemblance, such as is common to most acute infectious fevers, though that is striking enough, but beyond this there is a remarkable similarity in particular symptoms, in clinical course, and in complications. There is a tendency to regard buboes as a distinctive feature of plague, but these are found in a small moiety of cases of typhus fever. On the other side of the picture, the petechial eruptions of typhus, its most distinctive feature, are common enough in plague.

It is tempting to shirk the difficulty of a differential diagnosis by assuming that in Athens, as so often elsewhere, there was a simultaneous outbreak of typhus and plague, but the whole evidence points strongly to the presence of typhus, and typhus only. We will endeavour to present the evidence fairly and simply, so that every reader may form his own conclusion, by reference to the appended narrative of Thucydides.

Starting in Ethiopia rumour had it that the disease spread northwards to Egypt and Libya, and thence over the greater part of the Persian Empire, which at that time included almost all of Western Asia, then suddenly it swooped down upon Athens. The same disease was said to have previously attacked Lemnos and many other places, but with much less severity. With Lemnos Thucydides will have had close acquaintance, for it lay in the direct route to Thrace, where he owned property. He is careful to say that he gives this information as well as that of its starting-point and lines of extension only on hearsay evidence. If it were really part of one vast pandemic, it is surprising that he should have no more certain knowledge of its incidence. True, pestilence was raging this self-same year in Rome, but it must not be assumed that it was necessarily of the same character as that at Athens. All through the fifth century Rome was seldom without pestilence, and Livy and Dionysius of Halicarnassus record a succession of epidemics, some of several years’ duration, following hard one upon another. If the origin in Ethiopia and the subsequent lines of advance are to be accepted, this would certainly constitute a weighty argument in favour of Oriental plague. Of late years an endemic focus of plague has been located in Central Africa, and in its spread the disease was following established routes of commerce, as has habitually been the case. Pandemicity too is an inherent tendency of plague. Typhus has followed for the most part the march of armies, and in the wake of famine, and has shown but little tendency to adhere to the beaten routes of commerce. Typhus has in some instances extended at one and the same time over a wide region, but for the most part it has been over contiguous tracts of land. Thus Hildebrand recorded an epidemic spreading to the whole of Germany, Galicia, Hungary and the Austrian crown-lands.

Thucydides has laid it down that the plague of Athens was an unknown disease. Now there is a good deal of evidence to suggest that bubonic plague was recognized, in its sporadic form, as a clinical entity at the time of Thucydides. The language of a passage in the 2nd Book of the Epidemics, a treatise of the Hippocratic school, seems hardly susceptible of any other interpretation: ὁι ἐπὶ βουβῶσι πυρετοὶ κακόν, πλὴν τῶν ἐφημέρων, καὶ οἰ ἐπὶ πυρετοῖσι βουβῶνες κακίονες (‘fever supervening on buboes is a bad sign, except they be ephemeral: but buboes supervening on fever still worse’). The allusions also to buboes in Aristophanes are so numerous as almost to preclude any other conclusion: and it cannot be argued that these were an aftermath of the epidemic, for Thucydides[48] implicitly asserts the complete disappearance of the disease.

The outbreak of the pestilence first in the Piraeus suggests importation by sea. Sea-carriage is far more characteristic of plague than of typhus, though typhus has been imported often enough from Ireland into England, and was also brought back to England by the troops from Corunna, and to France by the French troops from the Crimea. On the other hand, it was in Piraeus chiefly that the displaced peasantry were crowded together promiscuously in small stifling habitations, affording just those conditions in which typhus has habitually arisen and become epidemic.

Among those epidemic diseases, that in past times have devastated beleaguered cities, typhus unquestionably holds pride of place. Granada in 1489, Metz in 1552, Montpellier in 1623, Reading in 1643, Genoa in 1799, Saragossa in 1808, Dantzig and Wilna in 1813, and Torgau in 1814 all tell the same tale. With our lately acquired knowledge of the transmission of typhus fever by the agency of body-lice, it is easy to understand the prevalence of the disease in epidemic virulence among a beleaguered and overcrowded garrison. Murchison, whose knowledge and experience of typhus were unequalled, unhesitatingly identified the plague of Athens as typhus, both because of this special circumstance of its occurrence and because of the clinical picture as a whole.

The passing remarks of Thucydides on the causation of the pestilence show him not only superior to the superstitious credulity of some of his fellow countrymen, but far in advance of the most enlightened medical opinion of his day. There were still some in Athens, who put their faith in supplications in temples and inquiries of oracles: but these measures were now weighed in the balance and found wanting. The stern probation of the Persian wars had taught the lesson, that victory was the reward of the strong, not the recompense of the devout; and with this knowledge perished the whole fabric of Greek polytheism. So now most of the populace ascribed the pestilence to natural causation: the Lacedaemonians surely had poisoned the wells. From this day onwards, right down to modern times, this phantom of poison dogs the footsteps of pestilence.

Thucydides leaves no doubt whatever as to his own views: he has done for good and all with supernatural causation, though he confesses his inability to identify the precise cause, leaving that for others to speculate about. He states and accepts without reserve contagion from man to man. In this his great contemporary, Hippocrates, lags far behind him. The mind of the Father of Medicine was still in bondage to the early Greek physicists. Conceiving disease to be caused in man by bodily disturbance, referable either to the character of the air inspired or of the food and drink ingested, it was inevitable that, in the causation of epidemic disease, Hippocrates should assign chief importance to changes in the atmosphere, to which all alike would be equally exposed. He does indeed recognize the possibility of its contamination with alien putrid effluvia, but for all that it is the mere physical changes in its constitution, which in his view are of paramount importance. Of contagion from man to man he had not the vaguest conception, and to him, as well as to Galen, and even to our own Sydenham, the sole criterion of epidemicity was the incidence of disease on a large number of persons at the same time.

To the student of the history of medicine it will be no matter for surprise that Thucydides should have seen with undimmed vision, what Hippocrates saw as yet only through a glass darkly. Medicine in every age has been the bond-servant of plausible preconceptions, and it is humiliating to professional self-complacency to scan the long array of lay writers from Thucydides onwards, who accepted contagion as a proven fact, before the scales fell from the eyes of obscurantist Science. Out of many we may enumerate Aristotle, Lucretius, Diodorus Siculus, Vergil, Ovid, Dionysius of Halicarnassus, Livy, Seneca, Silius Italicus, the elder Pliny, and Plutarch: while not till Aretaeus of Cappadocia, in the second century after Christ, do we meet clear and unequivocal acceptance in any medical author. Science, untempered by letters, is apt to induce a mental myopia, and we men of medicine would do well to reflect on the story of Archimedes, who, while drawing mathematical figures in the sand, overlooked to the cost of his life the fact, that the city had fallen into the hands of the enemy.