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.