In the year 1720 plague found its way to Marseilles. It was believed to
have been brought by a ship, the _Grand-Saint-Antoine_, which arrived
on May 25 from the Levant. As usual, the attempt was made to hush it up
for the sake of trade. At the beginning of August something had to be
done, so on the advice of two physicians, Sicard, father and son, it
was decided to light bonfires throughout the city. For lack of firewood
this was not done, but also for lack of faith, for it was found that
despite their vaunted specific, the Sicards had fled the city. So
sulphur was served out to the poor instead, wherewith to ‘perfume’
their houses.
As early as August 2 the Town Council found it necessary to adopt
special measures to keep physicians and surgeons to their task.
Accordingly, they decided that the city should pay them a fixed
salary in place of fees from the sick, and allow them smocks of oiled
cloth, and sedan chairs to carry them on their rounds. There are
several illustrations extant of the dress adopted by doctors in the
plague of Marseilles. The same dress, with trifling variations, was
worn elsewhere in France, in Switzerland, and in Germany, and had
originated in Italy. It is shown in an old Venetian woodcut of A.D.
1493, from the works of Joannes de Ketham (_Fasciculus Medicinae_,
1493). This woodcut shows a physician in a long overall, but wearing
only a skull-cap on his head, visiting a plague patient in bed. He is
accompanied by attendants who carry lighted torches, while he himself
holds a medicated sponge before his mouth and nose, as he feels the
pulse. Grillot figured the dress as the frontispiece of his _Lyon
affligé de la peste 1629_, and Manget[190] has borrowed it from him.
From his description it would seem that the mantle, breeches, shirt,
boots, gloves, and hat were all of morocco leather. The beak attached
to the mask was filled with aromatics, over which the air passed in
respiration, and had an aperture for each eye, fitted with a disk of
crystal.
[Illustration: PLATE XXVIII, 1. DRESS OF A MARSEILLES DOCTOR, 1720]
[Illustration: PLATE XXVIII, 2. GERMAN CARICATURE OF THE SAME
(Face Page 200)]
M. Reber[191] describes an engraving by John Melchior Fuesslin,
representing a doctor in the plague of Marseilles. The legend beneath
it, in German, is (translated) ‘Sketch of a Cordovan-leather-clad
doctor of Marseilles, having also a nose-case filled with smoking
material to keep off the plague. With the wand he is to feel the
pulse.’ Reber’s and Manget’s plates are both reproduced in the Bristol
_Medico-Chirurgical Journal_, March 1898, from the _Janus_ blocks.
Gaffarel[192] gives the costumes both of a doctor and of a hospital
attendant: they closely resemble the dress of the Italian charitable
guilds of the fifteenth and sixteenth centuries.
By August 9 some of the physicians and almost all the master-surgeons
had fled, and an ordinance was issued demanding their return, or in
default their expulsion from their respective corporations, and other
special penalties as well. Two physicians named Gayon volunteered
their services for the Hôpital des Convalescents, but forthwith paid
the penalty with their lives. In the absence of sufficient physicians
in Marseilles, others were summoned from Montpellier, Paris, and
elsewhere. These exhausted their energies in a dispute over the
contagious character of plague. Chicoyneau and Chirac maintained that
it was not contagious. Deidier proved, by successfully inoculating
dogs with bile taken from plague subjects, that at any rate it was
communicable. Each subsequently expounded his views in a formal
discourse before the School of Montpellier.
Existing hospital accommodation was quite unequal to the needs.
Emergency tents were erected outside the town, with mattresses for the
sick. Chevalier Rose equipped and maintained a hospital in the district
entrusted to him, at his own expense. A large temporary hospital of
timber covered with sail-cloth was hurriedly erected, but when almost
finished towards the end of September it was blown down by a gale,
and was not rebuilt till October 4. This hospital, together with
the Hôpital Général de la Charité of 800 beds, provided ultimately
sufficient accommodation, so that none need remain in the streets.
From the first the mortality was such that it was wellnigh impossible
to bury the dead. On August 8 the Assembly resolved that carts should
be used to carry the dead to burial, and that pits should be dug in
which the bodies could be buried in lime. So two huge pits were dug
outside the walls, between the gate of Aix and that of Joliette, M.
Moustier overseeing the diggers and compelling them to work. Chevalier
Rose also had pits dug and organized a corps of buriers in his own
district. The duties of burial were at first entrusted to sturdy
beggars, but in a brief space of time the supply of these failed,
so that bodies began to accumulate in the houses and streets. Then
convicts were requisitioned in relays from time to time.
These convicts were promised their liberty, to excite them to work—a
promise that was never fulfilled in the case of the few who survived
the task. Their ignorance of the management of carts and horses, their
idleness and lust of robbery rendered them so unfit for the task, that
Moustier and the other sheriffs and Chevalier Rose were compelled to
be always present on horseback, to superintend the work. By August 21
corpses had already begun to accumulate in old parts of the city, where
the streets were too narrow and steep for the carts to go. Accordingly,
an order was issued that the vaults of the churches in the upper town
should be used for burials in quicklime, and that, when full, they
should be sealed up with cement. By the end of August the streets
were literally strewn with dead bodies, some in an advanced stage of
putrefaction, mingled with cats and dogs that had been killed, and
bedding thrown out from the houses. The square in front of the building
called the Loge, as also the Palissadoes of the port, were filled with
bodies brought ashore from ships in the roadstead, to which whole
families had fled in the belief that plague would not reach them on the
water.
By September 6 more than 2,000 dead bodies were lying in the streets,
exclusive of those in the houses. On the esplanade called La Tourette,
lying towards the sea between the houses and the rampart, 1,000 corpses
had lain rotting for weeks in the sun and emitting a frightful stench.
They were too rotten even to be lifted into carts, and too foul to be
carried to distant pits. Chevalier Rose, mindful maybe of Procopius,
conceived the idea of throwing them into two huge vaults in the old
bastions close to the esplanade, after breaking in their roofs. The
task was carried out in fierce haste by 100 galley-slaves, who tied
handkerchiefs dipped in vinegar over their mouths and noses. At the
same time fishermen netted 10,000 dead dogs floating in the port and
towed them out to sea.
In the parish of St. Ferriol, the finest quarter of the city, Michel
Serre the painter undertook to see to the burial of the dead, with
carts and galley-slaves placed at his disposal, himself providing
food and lodging for the workers. A grateful city has repaid him by
hanging his two large pictures of Marseilles during the plague close
beneath the ceiling of an underground cellar, where it is impossible to
decipher their details.
When all the bodies were disposed of, the sheriffs employed the
galley-slaves to clear the filth from the streets and throw it into
barges, which carried it out to sea.
In the early days of the epidemic, the sheriffs had forbidden the
annual procession on August 16, in honour of St. Roch, at which the
saint’s bust and relics were carried through the streets; but the
people raised such an outcry that the procession was celebrated, the
sheriffs attending with their halberdiers to prevent a crowd following.
By September 7 even the civil authorities had come to regard the plague
as an instrument of God’s wrath, and the magistrates, to appease it,
vowed that every year the city should give 2,000 livres to a House of
Charity, to be established under the protection of our Lady of Good
Help, for orphans of the province.
At the height of the plague many parish priests and some of the monks
fled: the services of the Church were mostly suspended. But many
secular clergy and monks remained and devoted themselves unflinchingly
to the sick. The bishop, Belsunce, nobly played his part. Wherever the
poorest lay, there he went confessing, consoling, and exhorting them
to patience. To the dying he carried the Sacrament, to the destitute
the whole of his money in alms. Though plague invaded his palace and
carried off those about him, it spared him. It is of him that Pope[193]
asks,
Why drew Marseilles’ good Bishop purer breath
When nature sickened, and each gale was death?
On All Saints’ Day, Belsunce headed a procession through the streets
from his palace, walking barefoot, as Borromeo of old, with a halter
about his neck, and carrying the cross in his arms. He wished to appear
among his people as a scapegoat laden with their sins, and as a victim
destined to expiate them. Accompanied by the priests and canons of
the Church he led the way to a place where an altar had been erected.
There, after exhorting the people to repentance, he celebrated Mass
before them all. Then he solemnly consecrated the city to the Sacred
Heart of Jesus, in honour of which he had instituted a yearly festival.
The tears coursing down his face as he spoke moved all to cry aloud to
the Lord for mercy. On November 16 Belsunce was emboldened to exorcise
the waning plague. Calling together all that remained of the clergy
to the church of Acoulles, he read all the prayers that the Pope had
prescribed for deliverance from plague. Then after an eloquent and
moving exhortation he carried up the Holy Sacrament to the cathedral’s
roof, and there, under the open sky, with all the city lying before
him, uttered a solemn benediction, and performed the full ritual of
exorcism according to the forms of the Roman Catholic Church.
Belsunce was not the first human scapegoat to tread the streets
of Marseilles in voluntary expiation for its people. In times of
pestilence, in the old Greek colony of Massilia, one of the lower
orders offered himself on behalf of his fellow citizens. Dressed in
sacred garments and decked with sacred boughs he was led through the
streets, amid the prayers of the people that their ills might fall on
him, and then cast out of the city.
There stands this day on a lofty crest of land in the open square,
right in front of the episcopal palace of Marseilles, a statue of
Belsunce in bronze, by Ramus. The stone pedestal bears a commemorative
inscription and two reliefs in bronze. In one, Marseilles in woman’s
form is lying among her stricken children, while Belsunce and his
attendant priests implore the Sacred Heart to stay the plague. In the
other, Belsunce bears the Sacrament to sick and dying.
The statue of Belsunce, clad in full episcopal robes, stands with
face raised and arms outstretched to heaven, in attitude of earnest
supplication. Before him Nature has set a landscape of surpassing
beauty: sea, earth, and sky give freely of their best. Far down below a
polyglot people move hither and thither around the harbour quays, like
ants, at their appointed tasks. Beyond it spreads a matchless expanse
of Mediterranean sea, now smooth and silvery as a mirror, now fretful
with the rising tide. Away over the sea and over the low land that
bounds the bay, the evening sun lights up the face of Belsunce with
a last lingering radiance, as it goes down to its setting in a glory
of golden hues. If man’s graven image may enjoy the perfect happiness
denied to man, then surely Belsunce has his reward.
Marseilles is rich in reminiscence of her bishop. In the Bureau
d’Intendance Sanitaire hangs a pleasing portrait of Belsunce by
Gobert; while in the Musée may be seen a poor picture, by Mansian,
of him giving the Sacrament to the victims of the plague. François
Gérard (1770-1837) presented his ‘Peste de Marseille’ to the Bureau
d’Intendance Sanitaire, where now it hangs. The wan dismal colouring of
the picture accords ill with the striking vigour of the composition. In
the foreground is set forth the whole tragedy of a family stricken with
plague. On the ground lies the father writhing with agony: his hands
are clenched, his eyes are starting from their sockets: the dressing in
the right armpit indicates one site of the disease. The mother, seated
on a chest, clasps to her body her elder boy, wrapped in a blanket,
too weak to stand: the younger child leans against his mother, his
eyes fixed in terror on his dying father. Anguish is depicted in the
death-like pallor of the mother’s face. In the background Belsunce in
full robes distributes to the sick and starving poor the bread which an
attendant is carrying. To the left of the foreground bodies of the dead
are lying huddled up beneath an awning, while to the right convicts
are dragging corpses away for burial. The sublime serenity of the good
bishop seems to bring to his stricken people in their anguish some
promise of that peace which passeth all understanding.
[Illustration: PLATE XXIX (Face Page 206)
PESTE DE MARSEILLE. BY FRANÇOIS GÉRARD
Photograph by Giraudon, Paris]
[Illustration: PLATE XXX LA PESTE DANS LA VILLE DE MARSEILLE EN 1720
By J. F. de Troy (Face Page 207)]
J. F. de Troy the younger (1679-1752), himself an eye-witness of this
plague, painted a masterly picture, which is now in the city Musée. It
was executed for Chevalier Rose in 1722. It depicts him seated on a
white horse calmly directing the work of the convicts, who have been
assigned to him, as they clear the esplanade of La Tourette of the
accumulation of decomposing corpses. The sheriffs, also on horseback,
aid the Chevalier in his task. The ground is strewn with corpses, which
the convicts seize and hurl into the gaping mouths of the open vaults
in the bastions. They work in furious haste, impelled by the foul odour
of the bodies and the knowledge of the hazard of their task. Ferocity
is depicted in their faces, haste in all the movements of their bodies.
The whole scene is full of life and movement and spirit. In the sky
hover angels shaking flaming torches. The colouring has been managed
with wonderful effect to convey the feeling that sky and earth alike
are filled with a poisonous and sickly miasma.
In another picture in the Santé at Marseilles Guérin has treated the
same subject in a dull conventional manner. Chevalier Rose, bearing
the dead body of a woman, fills the centre of the picture. Behind him
a ludicrous boy is holding a white horse with one hand, and his nose
with the other, and is bestowing on his nose a tenacious grip that
would have been more appropriately bestowed on the horse. Convicts are
dragging away the dead bodies that litter the ground.
The two large pictures by Michel Serre are of interest rather as
pictorial records of old Marseilles, than as contributions to the
artistic presentation of plague. One represents the Cours de Marseille,
now known as the Cours Belsunce, during the plague. It is a handsome
boulevard bordered on either side by trees, beneath which are seen
tents hastily erected as temporary dwellings by those who have fled
from their plague-contaminated dwellings to the shelter of the streets.
Death and disease have followed them and are rampant on every side.
Buriers are seen collecting the dead and carrying them off in carts.
This picture has been engraved by Rigaud, and is figured in Crowle’s
_Illustrated Pennant’s London_, vol. x, p. 93; also in Gaffarel’s _La
Peste de 1720_, p. 304.
The other picture by Serre shows the open space in front of the Hôtel
de Ville together with part of the port of Marseilles. The scenes
resemble those of his other picture, and we are reminded also that
many took refuge in boats and anchored off the harbour, in the vain
belief that plague could not reach them there. The space before the
Town Hall became one heap of decomposing bodies that were landed
from the boats or had drifted ashore from the waters of the harbour.
Crowle[194] figures this picture as well as the preceding, so, too,
does Gaffarel.[195]
With the departure of plague from Marseilles, the disease had wellnigh
disappeared from Europe. In the Levant it still flourished for a while.
Patrick Russell, physician to the British factory at Aleppo, wrote a
treatise on an epidemic that occurred during his residence there from
1760-2. Again, in 1771 it gained a footing at Moscow, claiming there
no less than 80,000 victims. It was in vain that the people thronged
the miraculous _ikon_ of the Virgin at the Varvarka gate. Fearing the
great concourse, the archbishop had the _ikon_ removed to the Chudok
monastery, but such was the fury of the maddened people, that they
threatened to raze the building to the ground if the _ikon_ were not
restored. The archbishop yielded, but too late, for the mob dragged him
from his monastery and massacred him in the open street. From that day
the plague began to wane. So plague was banished from Europe by the
worship of a picture, and with dramatic appropriateness the curtain
fell on the final act in a scene of human sacrifice.
[Illustration: PLATE XXXI LES PESTIFÉRÉS DE JAFFA
By Baron Gros (Face Page 208)]
The celebrated picture ‘Les Pestiférés de Jaffa’ by Baron Gros, now
in the Louvre, has been the subject of much acrimonious controversy.
The picture was ordered by Napoleon when First Consul, and excited
extravagant enthusiasm on its exhibition in the Salon in 1804. Artists
placed a palm-branch over it, and the public covered the whole
frame with wreaths. It is, in fact, a large unattractive canvas,
devoid of any exceptional merit either of composition or colour. It
shows Napoleon accompanied by some of his staff standing among the
plague-stricken soldiers in the interior of a mosque. One of the men
is raising his right arm, so as to expose the bubo in his armpit, and
Napoleon is laying his fingers on it.
There is also in existence a rough sketch,[196] which shows that Gros
at the outset intended to present his subject differently. Napoleon,
like St. Louis in the modern fresco in St. Sulpice, holds in his arms
the body of a plague victim, which an Arab helps him to support. The
general’s impassive features contrast strongly with the frightened
appearance of his attendants.
Each of these two representations would seem to be actual historical
occurrences during Napoleon’s campaign in Syria. Plague had broken
out among the troops in Jaffa, where Napoleon had established a
large hospital, and the generals had issued an alarming report as to
its spread. It was Napoleon’s purpose to restore the _moral_ of his
army, which had been seriously affected by the outbreak. Norvin[197]
represents Napoleon as visiting all the wards, accompanied by the
generals Berthier and Bezzières, the director-general Daure, and the
head doctor Desgenettes. Napoleon spoke to the sick, encouraged them,
and touched their wounds, saying, ‘You see, it is nothing.’ When he
left the hospital, they blamed his imprudence. He replied coldly, ‘It
is my duty, I am the general-in-chief.’ This studied indifference to
the contagion, coupled with the fine behaviour of the head doctor
Desgenettes, who inoculated himself with plague in the presence of the
soldiers and applied to himself the same remedies as he prescribed
for them, successfully accomplished Napoleon’s purpose. The account
of the incident given in a letter[198] by Comte d’Aure is slightly
different. It runs, ‘He did more than touch the buboes: assisted by a
Turkish orderly, General Buonaparte picked up and carried away a plague
patient, who was lying across a doorway of one of the wards: we were
much frightened at his acting thus, because the sick man’s clothing
was covered with foam and the disgusting discharge from a broken bubo.
The general continued his visit unmoved and interested, spoke to the
sick, and sought in addressing them with words of consolation, to
dissipate the panic that the plague was casting on their spirits.’
Bourrienne,[199] Napoleon’s secretary, however, says, ‘I walked by the
general’s side, and I assert that I never saw him touch any of the
infected.’
The Duc de Rovigo in his _Memoirs_ practically corroborates the Comte
d’Aure. He says: ‘In order to convince them by the most obvious proof
that their apprehensions were groundless, he desired that the bleeding
tumour of one of his soldiers should be uncovered before him, and
pressed it with his own hands.’ Desgenettes and General Andréossy,
who were both present, confirm Rovigo and Comte d’Aure as against
Bourrienne.
Napoleon’s secretary carries the narrative a stage further. He says
that only sixty of those in the hospital had plague, and that as
their removal involved a risk of infecting the whole army, Napoleon
deliberated with his staff and the medical men, and decided to put them
out of their misery by poison. Bourrienne says that he does not know
who administered the poison, but that there was no question of their
destruction. Bourrienne’s statements on any subject, as is generally
recognized, need careful sifting, but out of the mass of conflicting
testimony the plain fact would seem to emerge, that Napoleon did
suggest that the death of some seven or eight, who were bound to die,
should be accelerated, so that they might not infect the whole army.
Napoleon himself, at St. Helena, did not deny this, and defended his
action on the ground of humanity, stigmatizing the story of wholesale
poisoning as an invention.
FOOTNOTES:
[190] _Traité de la Peste_, 2 vols., Genève, 1721; _Johns Hopkins
Hospital Bulletin_, August 1898.
[191] _Janus_, 1897, p. 297; and _Johns Hopkins Hospital Bulletin_.
[192] _La Peste de 1720_, p. 96.
[193] _Essay on Man_, iv. 107-8.
[194] vol. x, p. 91.
[195] p. 214.
[196] Richer, _L’Art et la médecine_.
[197] _Histoire de Napoléon_, ed. 1834, vol. i, p. 354.
[198] _Bourrienne et ses erreurs._
[199] _Mémoires sur Napoléon._
APPENDIX[200]
The statement of Thucydides, that all other diseases took on the
similitude of the dominating pestilence, is one that reappears
constantly in the literature of epidemic disease. We have already noted
the frequent concurrence of plague and typhus, leading such acute
observers as Diemerbroeck and Sydenham to believe that the one disease
might be transformed into the other. The same close association of
relapsing fever and typhus was constantly noted, and we know now that
the explanation lies in the fact that each disease is transmitted by
the body-louse, as plague is transmitted by the flea. Bearing in mind
the close and constant association of these and other acute infectious
fevers it is no matter for surprise that they should have been regarded
as states and stages of one pestilential process, differing from one
another, not in kind, but only in degree. As Bacon says, ‘putrefaction
rises not to its height at once.’
The acute, often abrupt, onset of the Athenian pestilence, with
profound depression, severe headache, and suffused conjunctivae, though
met with in a moiety of cases of plague, is eminently characteristic of
typhus. The striking appearance of the bloodshot eyeballs has led to
much confusion between the two diseases.
The aspect of the tongue and fauces inclines rather to the side of
typhus. In each disease the tongue is at first heavily coated with a
thick white fur, and tends later to become dry and parched. But in
typhus there is a special tendency, as the disease advances, for the
tongue to bleed from fissures at the edges. So frequently is this the
case, that this feature has been regarded as of diagnostic value in the
presence of an outbreak of typhus. A boggy reddened appearance of the
fauces is usual in typhus, and is seen also in a proportion of plague
patients.
Unnatural and even foetid breath may be met with in any acute
infectious fever, but foetor is in no way characteristic of any.
Doubtless it was far more common in times when the alphabet of oral
hygiene had not yet found acceptance as a necessary detail of medical
regimen. Murchison describes the breath of typhus patients as foetid,
and in addition it is well known that a repulsive odour may be given
off from their bodies. Salius Diversus mentioned it three centuries
ago, and it has been a commonplace of many subsequent writers.
Curschmann failed to detect it, and attributed its absence to the free
ventilation of the sick wards. A layman, as Thucydides was, might well
ascribe to the breath a foetor permeating the whole atmosphere around
the patient.
Sneezing has long been associated in popular tradition with plague,
and an old legend refers the association to the plague of Rome at the
commencement of the pontificate of Gregory the Great, when it is said
that those who sneezed died. The most careful and observant of modern
physicians do not, however confirm the connexion. Russell states that
he was on the look out for it during the plague of Aleppo and did
not observe it: Simpson does not even mention it. Nor does it appear
to be noteworthy as a symptom either of typhus or of any other acute
infectious fever, though it would be in accord with the swollen and
congested state of the nasal mucosa in typhus, to which Curschmann
has drawn special attention. Perhaps the tradition is a mere old
wives’ tale, for sneezing has been regarded as an ominous sign from
great antiquity, and as far back at least as the composition of the
_Odyssey_. Aristotle frankly confessed himself unable to explain the
connexion.
Curschmann met with hoarseness and laryngeal catarrh commonly in
typhus, but though catarrh of the whole respiratory tract may occur
in plague, it is not an outstanding feature. Cough is frequent in
either disease; so also is vomiting, often of great severity: and if
protracted will exhibit a succession of changes of colour, such as
Thucydides has described, first the food contents of the stomach, then
green bilious vomit, and finally blood, either red or altered to brown
or black. Hiccough and empty retching are liable to ensue on severe
vomiting from any enduring cause.
It is not clear to what Thucydides appropriates the term σπασμός: the
context would suggest that spasm of the diaphragm, such as accompanies
protracted vomiting, is indicated. But it may also signify true
convulsions, which are an occasional complication of both diseases.
Convulsive tremor of the limbs, and indeed of the whole body, is
habitual at the height of typhus, and is not infrequent in plague.
We should naturally look to the appearance of the skin and of the
eruption to afford criteria for a sure diagnosis, but such is not
the case. True, there is a remarkable resemblance to Murchison’s
description of the skin of typhus patients, in an English hospital.
‘The face’, he says, ‘is often flushed. The flushing is general over
the entire face. It is never pink: sometimes it is reddish or reddish
brown, but more commonly it is of a dusky, earthy, or leaden hue: in
grave cases it may be livid.’ No corresponding appearance of the skin
is to be seen in plague.
Thucydides has described the eruption as consisting of φλύκταιναι
μικραὶ καὶ ἕλκη, words that have generally been rendered as ‘small
blisters and ulcers’, and for this reason have been held to exclude
positively a diagnosis of typhus fever. So certain a conclusion is
hardly justified by the facts. Outbreaks of gangrenous dermatitis, in
which multiple bullae or blisters, leaving an ulcerated base, have
broken out over the body surface, have been not uncommon features of a
typhus epidemic, and from their virulently contagious character such
outbreaks would have been more prone to occur amid all the neglect
and destitution of a beleaguered garrison. Murchison has described
the resulting appearances in the following words: ‘I have seen bullae
filled with light or dark fluid, or large pustules appear on various
parts of the body during the progress of the fever. Stokes has observed
bullae of this description followed after bursting by deep ulcers with
sharp margins.’ But extensive ulceration such as this must inevitably
have left permanent scarring, at least as marked as the ‘pitting’
produced by small-pox, and we can hardly presume that this could have
escaped the critical Greek eye of so keen an observer as Thucydides.
The whole question arises of the exact significance of the words ἕλκος
and φλύκταινα.
In his treatise Περὶ Ἑλκῶν Hippocrates uses the term ἕλκος not only
for open wounds and ulcers, but also for burns, wheals, and wounds in
general.
Homer uses it for wounds of every kind. It so happens that the wounds
of the _Iliad_ are almost all the open wounds produced by spear and
arrow, but Homer also uses it for the bite of a snake[201] and for the
wound inflicted by lightning.[202]
Bion[203] uses it in consecutive lines for the wound caused by a spear,
and in the generic sense:
Ἃγριον, ἄγριον ἓλκος ἔχει κατὰ μηρὸν Αδωνις,
μεῖζον δ’ ἁ Κυθέρεια φέρει ποτικάρδιον ἕλκος.
Aeschylus[204] and Sophocles[205] use it also in the wider sense, as in
πόλει μὲν ἕλκος ἕν τὸ δήμιον τυχεῖν
and
τί γὰρ
γένοιτ’ ἄν ἕλκος μεῖζον ἤ φίλος κακός;
The inference to be drawn from these passages is that ἕλκος, although
usually indicating an open wound, is used with no precise significance.
The same difficulty attaches to the word φλύκταινα. Though Hippocrates
uses the word frequently, there is no single passage in which
the precise significance is clear beyond all doubt. He applies
it to chilblains,[206] to an eruption on the skin of subjects of
empyema,[207] to lesions appearing on the tongue in fatal septic cases,
and so on. In one passage, in which he speaks of a φλύκταινα arising
from rubbing the skin with vinegar, he seems to indicate a blister.
The first clear definition of the term we have is from the pen of
Celsus, who defines it as a discoloured pustule that breaks and leaves
an ulcerated base (‘genus pustularum, cum plures similes varis oriuntur
nonnunquam maiores, lividae aut pallidae aut nigrae aut aliter naturali
colore mutato: subestque iis humor, ubi hae ruptae sunt, infra quasi
exulcerata caro apparet’). There are several passages in Aristophanes,
which indicate that he at any rate applied the term as we do to a
blister lesion: but at the same time, there are other passages in
which this exclusive use is by no means so sure. The lesion resulting
from rowing[208] or carrying a lance[209] cannot well be other than
a blister. And there is a passage in the _Ecclesiazusae_,[210] which
seems even clearer:
ἀλλ’ ἔμπουσά τις
ἐξ ἁἵματος φλύκταιναν ἠμφιεσμένη,
‘Some vampire bloated with blood like a blister.’
The image must be that of a vampire, so bloated with blood, that its
body seems actually enveloped in it, simulating a blood-blister.
Aristotle applies the term to the bite of a shrew-mouse, which would
presumably produce a solid local swelling, and not a blister. Procopius
uses φλύκταινα for the black cutaneous lesions of Oriental plague,
known nowadays as pustules: he says, too, that they were of the size
of a lentil, but does not mention terminal ulceration. Procopius is so
precise in his medical terminology, that it is improbable he borrowed
the term from Thucydides without appreciating its exact significance:
far more likely he adopted it from the medical terminology of his day.
There is something to be said for appropriating the terms used by
Thucydides to the pustular lesions of Oriental plague. Many writers,
ancient as well as modern, have described the so-called pustules as
commencing in some cases as blisters and terminating in eroding ulcers.
But, on the other hand, we know nothing of epidemics of plague without
a considerable proportion of bubonic cases, while we do know from
the narrative of Procopius that plague has maintained its characters
unchanged for 1,500 years. In an epidemic of plague, in which death
did not supervene till the seventh or ninth day the presence of buboes
would be the outstanding feature of the disease, and Thucydides does
not even mention them.
Assuming that typhus fever also has maintained its characters
unchanged, and that the external manifestations of the Athenian
pestilence were not of the exceptional type we have alluded to, but of
the type habitually associated with the disease, can it reasonably be
contended that the terms φλύκταινα and ἕλκη are applicable to these?
Murchison says that ‘according to its colour, the eruption may be said
to pass through three stages, viz. 1, Pale dirty pink or florid; 2,
reddish brown or rusty; 3, livid or petechial’. In the first stage, it
is generally admitted that except on careful observation, and in a good
light, the faint diffuse maculae (spots) are apt to escape detection,
so that the impression is of a general suffusion of the skin—what in
fact Thucydides terms ὑπέρυθρον.
In the second stage, the deeper coloration of the spots throws them
into relief as individual lesions against the paler background of
general suffusion of the skin. Can it be that this is indicated by the
vague term φλύκταινα? Be it remembered that Thucydides was a layman,
describing, as he says, the lesions of a hitherto unknown disease.
Every physician is well aware of the restricted terminology that the
laity possess for the description of multifarious lesions. Medicine
itself is not exempt from the same confusion, for when physicians
glibly speak of the subcutaneous haemorrhages of typhus as petechiae
they forget that the word throws back to _petigo_ (a scab).
There remains then for the third stage of the eruption—the
haemorrhagic stage—the term ἕλκος, a generic term applicable to almost
any lesion, and having no philological affinity to the Latin _ulcus_,
and the English ‘ulcer’, with which medical usage has confused it.
Reviewing, then, all the facts, it cannot be held that the description
of the eruption, as given by Thucydides, is sufficient to negative a
diagnosis of typhus fever, which disease is otherwise depicted to the
life in all else that he says of its clinical course and characters.
Thucydides was so impressed with the intensity of the internal fever,
that he expected certainly to find a corresponding temperature of
the body surface: hence his surprise is obvious at finding it not
excessively hot. For all that, sufferers were ready to cast off
every shred of clothing, till they were naked, and longed to throw
themselves into cold water. Some did actually plunge into cisterns,
but no amount of water sufficed to slake their thirst. Procopius
mentions this same fierce longing to fling themselves into water among
the plague victims of Byzantium, but raving delirium of this kind is
far more characteristic of typhus than of plague. Curschmann depicts
the fierce medley of wild ravings, mingled with frantic efforts at
self-destruction, which give an unmistakable character to a ward of
typhus patients. Murchison, quoting from Bancroft, says: ‘Some leaving
their beds would beat their keepers or nurses and drive them from
their presence: others, like madmen, would run about the streets,
markets, lanes, and other places: and some again would leap headlong
into deep waters.’ Intolerable restlessness and insomnia fill up the
cup of misery to overflowing. Curschmann confirms the observation of
Thucydides, that typhus cadavers exhibit very little emaciation, but
this does not help to differentiate typhus from other acute fevers of
equally brief duration.
Death commonly occurred on the seventh or the ninth day. One recognizes
here submission to the authoritative doctrine of critical days.
Hippocrates[211] defined them on the basis of equal and unequal numbers:
Equal—4, 6, 8, 10, 14, 28, 30, 48, 60, 80, 100.
Unequal—5, 7, 9, 11, 17, 21, 27, 31.
Taking the mean of the numbers, the plague of Athens claimed its
victims for the most part about the eighth day of the disease. A layman
would hardly have had the opportunity, or indeed the inclination,
to make an exact statistical computation, and in this fact perhaps
lies this unexpected lapse of Thucydides into subservience to medical
orthodoxy.
With regard to the day of death in typhus fever, Curschmann says:
‘When death is caused simply by the severity of the disease, it
occurs usually in the middle or second half of the second week. A
fatal termination before the ninth day, or as early as the fifth or
sixth day, occurs only in the most severe forms of the disease, or
in individuals with little resisting power.’ Now, not only was the
Athenian pestilence severe in type, but there was also an almost
complete absence of the nursing and medical regimen that will have
served to prolong the duration of cases, that have ultimately proved
fatal, in recent epidemics. In plague death usually occurs between the
second and sixth days, seldom later, and few patients survive to the
seventh or ninth day without the appearance of buboes.
If the victims survived this period, the disease fastened on the bowels
and produced violent ulceration (ἕλκωσις). Initial constipation,
followed, as the disease develops, by diarrhoea, which is sometimes
profuse and intractable, is met with both in typhus and plague.
The disease began in the head and gradually passed through the whole
body. If the sufferer survived so long, it would often seize the
extremities and make its mark, attacking the privy parts and fingers
and toes. Some escaped with the loss of these and with the loss of
their eyes. This terminal gangrene of the extremities is of frequent
occurrence in typhus, but is rare in plague, and very rare in other
acute infectious fevers. Curschmann says: ‘Many patients continue
to suffer for some time after defervescence (of typhus fever) from
gangrene of the ears, fingers, toes, tip of the nose, and skin of the
penis and scrotum, arising during the febrile period.’ Gangrenous
changes around a carbuncle are occasional in plague, but not as an
independent affection of the extremities. Neglected plague buboes, even
nowadays in Indian epidemics, do exceptionally become gangrenous, as
the result of an intercurrent erysipelas. Necrotic ulceration of the
eyeballs is well authenticated as a complication of typhus as well as
of plague.
Some recovered from the disease, but with complete loss of memory.
This again is a frequent consequence, usually temporary, but sometimes
permanent, of typhus. According to Curschmann, ‘the patient’s
recollection of his illness is almost always very limited in severe
or moderately severe cases. True psychoses appear to be rare during
convalescence. Mild melancholia and hallucinations are sometimes seen,
and even mania has been observed.’
The combination of gangrene with mental symptoms inevitably suggests
the thought of ergotism (poisoning by a fungus of rye-grain), and
Read and Kobert have expended much ingenuity in support of this
hypothesis. One of the Athenian corn routes did actually tap the
northern shores of the Euxine, and southern Russia has been one of the
chief centres of epidemics of ergotism. But there is no need to invoke
this condition, to explain symptoms which are commonly encountered in
typhus, and no warrant either for so doing, seeing that the clinical
features of the visitation had little in common with ergotism. Kobert’s
ingenious arguments in favour of ergotism, superimposed on some other
unidentified disease, merely substitute one _impasse_ for another.
Thucydides observes that one feature distinguished the Athenian
pestilence from ordinary diseases. Birds and beasts of prey, which feed
on human flesh, would not as a rule touch the bodies, but, if they did,
they died. In fact, the birds of prey disappeared altogether, and were
not to be seen either about the bodies or anywhere else. In the case of
the dogs this was particularly noticeable, because they live with man.
The paragraph is curiously involved, but contains three statements of
fact:
1. That vultures were nowhere to be seen.
2. That dogs avoided the dead bodies, as a rule, but
that, when they did not, they took the disease.
3. That other animals, which feed on carrion, and
within the walls of Athens these can hardly have
been other than rats and cats, and possibly pigs,
were affected like the dogs.
There is no evidence as to the effect on cattle, horses, sheep, and
goats, because all these had been removed to Euboea.
The phenomenon of the disappearance of birds of prey before and during
outbreaks of epidemic pestilence has been asserted again and again in
literature. Yet it is very doubtful if the observation rests on any
sure evidence. Search has brought to light only one occasion on which
the truth of the fact has been deliberately tested, and then it was
directly contradicted. Russell says that at the commencement of the
plague of Aleppo, in which true plague was ushered in by typhus, no
desertion of birds was observed, and no mortality among cattle. The
old-time fancy that pestilence engendered in the clouds distempered
the atmosphere almost necessarily involved the presumption that the
feathered inhabitants of the air would be the first to feel its ill
effects. In the same way the belief that pestilence might reach the
atmosphere in the exhalations from marshes, led to similar fables
attaching themselves to the marsh-dwelling frog. Aristotle alludes
to the increased number of frogs in pestilential years, and Bacon
and Horstius repeat his statement. These children of the marsh are
conceived of as products of its undue activity. Horstius went so far as
to assert the same of snails.
Livy[212] clearly asserts the disappearance of vultures from Rome
before and during the epidemic of 174 B.C. ‘Cadavera, intacta a canibus
et vulturibus, tabes absumebat: satisque constabat, nec illo, nec
priore anno, in tanta strage boum hominumque vulturium usquam visum.’
[Dead bodies rotted away, untouched by dogs and vultures: and it was
generally agreed that no vultures were to be seen either in that or the
preceding year in spite of so great a mortality of men and cattle.] In
this instance, then, it was not that they scented death from afar and
held aloof, but that they disappeared beforehand. If some undetected
epizootic—say of rats—had preceded the outbreak among cattle and
men, the vultures may well have perished at the outset from feeding on
infected material.
Other authors extend the observation to birds in general, and not only
to birds of prey, as though their affection was truly epizootic. Thus
Schenkius[213] says that in the plagues of 1505 and 1522 birds deserted
their nests and young ones. Goclenius says the same of the plague of
1612, and that they fell suddenly to the ground dead. Mercurialis
says that Venice was deserted by birds in 1576, and Short repeats
this of Dantzig in 1709. Diemerbroeck says that cage-birds died in
the epidemics of 1635 and 1636, and Sorbait records the same fact of
the Viennese pestilence of 1679. Most, if not all this succession of
epidemics, were unquestionably true Oriental plague, with or without
typhus.
At present there is very little evidence of any extensive affection
of the lower animals by typhus. Mosler, many years ago, failed to
communicate it to dogs by injecting fresh typhus blood into their
veins, or by feeding them on fresh typhus excreta, although death
with typhoid symptoms followed, when the blood and stools had first
been allowed to decompose. In the last few years experimenters have
succeeded in communicating the disease to various monkeys by the
agency of lice, but dogs, rats, and guinea-pigs have hitherto proved
refractory to infection.
On the other hand, there is abundant evidence of animal infection
with Oriental plague. Epizootics among rats and cats are well known.
Boccaccio asserted the susceptibility of pigs, and Michoud confirmed
the observation in the Yunnan epidemic of 1893. Dogs, poultry, deer,
cattle, monkeys, squirrels, and marmots have all been shown by various
observers to be prone to contagion.
Before accepting the evidence of Thucydides as to the disappearance of
birds as weighty evidence in favour of the presence of true plague,
one must consider the state of the country district around Athens,
devastated by fire and the sword, and denuded of all its stock, so as
to offer no promise of sustenance to bird visitors. But even so, one
is still confronted by his statement as to the domestic dogs, which
are known to be susceptible to plague and not known to be susceptible
to typhus.
Thucydides says that no one was attacked a second time, or if he
were the result was not fatal. Immunity of this kind, comparatively
complete, is alike characteristic of typhus and plague: the question
is one that has provoked considerable controversy right down to modern
times. Both Curschmann and Murchison are agreed as to the extreme
rarity of relapses and reinfections in typhus: curiously, Murchison
himself had two typical severe attacks.
In the case of plague, Alexander Massaria,[214] from his experience at
Vicenza, came to the conclusion that one attack rendered a man immune
with very few exceptions, but that a second attack might be mortal.
Mercurialis and Van Helmont were in agreement as to the rarity of
second attacks. Diemerbroeck[215] recorded two cases of reinfection
in the same year of the plague at Nymwegen, and several cases at an
interval of a few years. During the plague of Marseilles in 1720,
various writers observed cases of reinfection, and relapse was also
said to be frequent. In the plague of 1771 at Moscow, Samilowitz,
prejudiced by his own advocacy of inoculation, denied the existence
of reinfection, and suffered retribution for his dogmatism by three
relapses in his own person. In the same plague both Mertens and Orraeus
recorded cases of reinfection. In the plague of Aleppo, Russell noted
28 cases of reinfection within three years among 4,400 victims of
plague. Thus the idea of complete immunity, so prevalent popularly both
in Europe and the Levant, must be accepted with some reservation.
OXFORD: HORACE HART M.A. PRINTER TO THE UNIVERSITY
FOOTNOTES:
[200] Curschmann’s contribution, in Nothnagel’s _Encyclopaedia of
Practical Medicine_, is perhaps the most graphic and succinct account
of Typhus Fever in modern medical literature. The record of Thucydides
should be studied closely side by side with this. Murchison’s article,
in his _Treatise on Continued Fever_, though admirable, is so diffuse
as to make comparison difficult.
[201] _Iliad_ ii. 723.
[202] _Iliad_ viii. 405 and 419.
[203] _Adonis_, 16-17.
[204] _Agamemnon_, 645.
[205] _Antigone_, 652.
[206] _On Ancient Medicine_, § 16.
[207] _Coacae Praenotiones_, § 396.
[208] _Frogs_, 236.
[209] _Wasps_, 1119.
[210] _Ecclesiazusae_, 1057.
[211] _Epidemics_, iii.
[212] xli. 21.
[213] _Obs._ p. 870.
[214] _Tract. de Peste_, ed. 1669, p. 509.
[215] _De Peste_, Lib. IV. Hist. 37. 45.