Historic Public Health Books

CHAPTER II--THE DISEASE

The most memorable example of what has been advanced is afforded by a great pestilence of the fourteenth century, which desolated Asia, Europe, and Africa, and of which the people yet preserve the remembrance in gloomy traditions. It was an oriental plague, marked by inflammatory boils and tumours of the glands, such as break out in no other febrile disease. On account of these inflammatory boils, and from the black spots, indicatory of a putrid decomposition, which appeared upon the skin, it was called in Germany and in the northern kingdoms of Europe the Black Death, and in Italy, la mortalega grande, the Great Mortality.

Few testimonies are presented to us respecting its symptoms and its course, yet these are sufficient to throw light upon the form of the malady, and they are worthy of credence, from their coincidence with the signs of the same disease in modern times.

The imperial writer, Kantakusenos, whose own son, Andronikus, died of this plague in Constantinople, notices great imposthumes of the thighs and arms of those affected, which, when opened, afforded relief by the discharge of an offensive matter. Buboes, which are the infallible signs of the oriental plague, are thus plainly indicated, for he makes separate mention of smaller boils on the arms and in the face, as also in other parts of the body, and clearly distinguishes these from the blisters, which are no less produced by plague in all its forms. In many cases, black spots broke out all over the body, either single, or united and confluent.

These symptoms were not all found in every case. In many, one alone was sufficient to cause death, while some patients recovered, contrary to expectation, though afflicted with all. Symptoms of cephalic affection were frequent; many patients became stupefied and fell into a deep sleep, losing also their speech from palsy of the tongue; others remained sleepless and without rest. The fauces and tongue were black, and as if suffused with blood; no beverage could assuage their burning thirst, so that their sufferings continued without alleviation until terminated by death, which many in their despair accelerated with their own hands. Contagion was evident, for attendants caught the disease of their relations and friends, and many houses in the capital were bereft even of their last inhabitant. Thus far the ordinary circumstances only of the oriental plague occurred. Still deeper sufferings, however, were connected with this pestilence, such as have not been felt at other times; the organs of respiration were seized with a putrid inflammation; a violent pain in the chest attacked the patient; blood was expectorated, and the breath diffused a pestiferous odour.

In the West, the following were the predominating symptoms on the eruption of this disease. An ardent fever, accompanied by an evacuation of blood, proved fatal in the first three days. It appears that buboes and inflammatory boils did not at first come out at all, but that the disease, in the form of carbuncular (anthrax-artigen) affection of the lungs, effected the destruction of life before the other symptoms were developed.

Thus did the plague rage in Avignon for six or eight weeks, and the pestilential breath of the sick, who expectorated blood, caused a terrible contagion far and near; for even the vicinity of those who had fallen ill of plague was certain death; so that parents abandoned their infected children, and all the ties of kindred were dissolved. After this period, buboes in the axilla and in the groin, and inflammatory boils all over the body, made their appearance; but it was not until seven months afterwards that some patients recovered with matured buboes, as in the ordinary milder form of plague.

Such is the report of the courageous Guy de Chauliac, who vindicated the honour of medicine, by bidding defiance to danger; boldly and constantly assisting the affected, and disdaining the excuse of his colleagues, who held the Arabian notion, that medical aid was unavailing, and that the contagion justified flight. He saw the plague twice in Avignon, first in the year 1348, from January to August, and then twelve years later, in the autumn, when it returned from Germany, and for nine months spread general distress and terror. The first time it raged chiefly among the poor, but in the year 1360, more among the higher classes. It now also destroyed a great many children, whom it had formerly spared, and but few women.

The like was seen in Egypt. Here also inflammation of the lungs was predominant, and destroyed quickly and infallibly, with burning heat and expectoration of blood. Here too the breath of the sick spread a deadly contagion, and human aid was as vain as it was destructive to those who approached the infected.

Boccacio, who was an eye-witness of its incredible fatality in Florence, the seat of the revival of science, gives a more lively description of the attack of the disease than his non-medical contemporaries.

It commenced here, not as in the East, with bleeding at the nose, a sure sign of inevitable death; but there took place at the beginning, both in men and women, tumours in the groin and in the axilla, varying in circumference up to the size of an apple or an egg, and called by the people, pest-boils (gavoccioli). Then there appeared similar tumours indiscriminately over all parts of the body, and black or blue spots came out on the arms or thighs, or on other parts, either single and large, or small and thickly studded. These spots proved equally fatal with the pest-boils, which had been from the first regarded as a sure sign of death. No power of medicine brought relief--almost all died within the first three days, some sooner, some later, after the appearance of these signs, and for the most part entirely without fever or other symptoms. The plague spread itself with the greater fury, as it communicated from the sick to the healthy, like fire among dry and oily fuel, and even contact with the clothes and other articles which had been used by the infected, seemed to induce the disease. As it advanced, not only men, but animals fell sick and shortly expired, if they had touched things belonging to the diseased or dead. Thus Boccacio himself saw two hogs on the rags of a person who had died of plague, after staggering about for a short time, fall down dead as if they had taken poison. In other places multitudes of dogs, cats, fowls, and other animals, fell victims to the contagion; and it is to be presumed that other epizootes among animals likewise took place, although the ignorant writers of the fourteenth century are silent on this point.

In Germany there was a repetition in every respect of the same phenomena. The infallible signs of the oriental bubo-plague with its inevitable contagion were found there as everywhere else; but the mortality was not nearly so great as in the other parts of Europe. The accounts do not all make mention of the spitting of blood, the diagnostic symptom of this fatal pestilence; we are not, however, thence to conclude that there was any considerable mitigation or modification of the disease, for we must not only take into account the defectiveness of the chronicles, but that isolated testimonies are often contradicted by many others. Thus the chronicles of Strasburg, which only take notice of boils and glandular swellings in the axillae and groins, are opposed by another account, according to which the mortal spitting of blood was met with in Germany; but this again is rendered suspicious, as the narrator postpones the death of those who were thus affected, to the sixth, and (even the) eighth day, whereas, no other author sanctions so long a course of the disease; and even in Strasburg, where a mitigation of the plague may, with most probability, be assumed since the year 1349, only 16,000 people were carried off, the generality expired by the third or fourth day. In Austria, and especially in Vienna, the plague was fully as malignant as anywhere, so that the patients who had red spots and black boils, as well as those afflicted with tumid glands, died about the third day; and lastly, very frequent sudden deaths occurred on the coasts of the North Sea and in Westphalia, without any further development of the malady.

To France, this plague came in a northern direction from Avignon, and was there more destructive than in Germany, so that in many places not more than two in twenty of the inhabitants survived. Many were struck, as if by lightning, and died on the spot, and this more frequently among the young and strong than the old; patients with enlarged glands in the axillae and groins scarcely survive two or three days; and no sooner did these fatal signs appear, than they bid adieu to the world, and sought consolation only in the absolution which Pope Clement VI. promised them in the hour of death.

In England the malady appeared, as at Avignon, with spitting of blood, and with the same fatality, so that the sick who were afflicted either with this symptom or with vomiting of blood, died in some cases immediately, in others within twelve hours, or at the latest two days. The inflammatory boils and buboes in the groins and axillae were recognised at once as prognosticating a fatal issue, and those were past all hope of recovery in whom they arose in numbers all over the body. It was not till towards the close of the plague that they ventured to open, by incision, these hard and dry boils, when matter flowed from them in small quantity, and thus, by compelling nature to a critical suppuration, many patients were saved. Every spot which the sick had touched, their breath, their clothes, spread the contagion; and, as in all other places, the attendants and friends who were either blind to their danger, or heroically despised it, fell a sacrifice to their sympathy. Even the eyes of the patient were considered a sources of contagion, which had the power of acting at a distance, whether on account of their unwonted lustre, or the distortion which they always suffer in plague, or whether in conformity with an ancient notion, according to which the sight was considered as the bearer of a demoniacal enchantment. Flight from infected cities seldom availed the fearful, for the germ of the disease adhered to them, and they fell sick, remote from assistance, in the solitude of their country houses.

Thus did the plague spread over England with unexampled rapidity, after it had first broken out in the county of Dorset, whence it advanced through the counties of Devon and Somerset, to Bristol, and thence reached Gloucester, Oxford and London. Probably few places escaped, perhaps not any; for the annuals of contemporaries report that throughout the land only a tenth part of the inhabitants remained alive.

From England the contagion was carried by a ship to Bergen, the capital of Norway, where the plague then broke out in its most frightful form, with vomiting of blood; and throughout the whole country, spared not more than a third of the inhabitants. The sailors found no refuge in their ships; and vessels were often seen driving about on the ocean and drifting on shore, whose crews had perished to the last man.

In Poland the affected were attacked with spitting blood, and died in a few days in such vast numbers, that, as it has been affirmed, scarcely a fourth of the inhabitants were left.

Finally, in Russia the plague appeared two years later than in Southern Europe; yet here again, with the same symptoms as elsewhere. Russian contemporaries have recorded that it began with rigor, heat, and darting pain in the shoulders and back; that it was accompanied by spitting of blood, and terminated fatally in two, or at most three days. It is not till the year 1360 that we find buboes mentioned as occurring in the neck, in the axillae, and in the groins, which are stated to have broken out when the spitting of blood had continued some time. According to the experience of Western Europe, however, it cannot be assumed that these symptoms did not appear at an earlier period.

Thus much, from authentic sources, on the nature of the Black Death. The descriptions which have been communicated contain, with a few unimportant exceptions, all the symptoms of the oriental plague which have been observed in more modern times. No doubt can obtain on this point. The facts are placed clearly before our eyes. We must, however, bear in mind that this violent disease does not always appear in the same form, and that while the essence of the poison which it produces, and which is separated so abundantly from the body of the patient, remains unchanged, it is proteiform in its varieties, from the almost imperceptible vesicle, unaccompanied by fever, which exists for some time before it extends its poison inwardly, and then excites fever and buboes, to the fatal form in which carbuncular inflammations fall upon the most important viscera.

Such was the form which the plague assumed in the fourteenth century, for the accompanying chest affection which appeared in all the countries whereof we have received any account, cannot, on a comparison with similar and familiar symptoms, be considered as any other than the inflammation of the lungs of modern medicine, a disease which at present only appears sporadically, and, owing to a putrid decomposition of the fluids, is probably combined with hemorrhages from the vessels of the lungs. Now, as every carbuncle, whether it be cutaneous or internal, generates in abundance the matter of contagion which has given rise to it, so, therefore, must the breath of the affected have been poisonous in this plague, and on this account its power of contagion wonderfully increased; wherefore the opinion appears incontrovertible, that owing to the accumulated numbers of the diseased, not only individual chambers and houses, but whole cities were infected, which, moreover, in the Middle Ages, were, with few exceptions, narrowly built, kept in a filthy state, and surrounded with stagnant ditches. Flight was, in consequence, of no avail to the timid; for even though they had sedulously avoided all communication with the diseased and the suspected, yet their clothes were saturated with the pestiferous atmosphere, and every inspiration imparted to them the seeds of the destructive malady, which, in the greater number of cases, germinated with but too much fertility. Add to which, the usual propagation of the plague through clothes, beds, and a thousand other things to which the pestilential poison adheres--a propagation which, from want of caution, must have been infinitely multiplied; and since articles of this kind, removed from the access of air, not only retain the matter of contagion for an indefinite period, but also increase its activity and engender it like a living being, frightful ill- consequences followed for many years after the first fury of the pestilence was past.

The affection of the stomach, often mentioned in vague terms, and occasionally as a vomiting of blood, was doubtless only a subordinate symptom, even if it be admitted that actual hematemesis did occur. For the difficulty of distinguishing a flow of blood from the stomach, from a pulmonic expectoration of that fluid, is, to non-medical men, even in common cases, not inconsiderable. How much greater then must it have been in so terrible a disease, where assistants could not venture to approach the sick without exposing themselves to certain death? Only two medical descriptions of the malady have reached us, the one by the brave Guy de Chauliac, the other by Raymond Chalin de Vinario, a very experienced scholar, who was well versed in the learning of the time. The former takes notice only of fatal coughing of blood; the latter, besides this, notices epistaxis, hematuria, and fluxes of blood from the bowels, as symptoms of such decided and speedy mortality, that those patients in whom they were observed usually died on the same or the following day.

That a vomiting of blood may not, here and there, have taken place, perhaps have been even prevalent in many places, is, from a consideration of the nature of the disease, by no means to be denied; for every putrid decomposition of the fluids begets a tendency to hemorrhages of all kinds. Here, however, it is a question of historical certainty, which, after these doubts, is by no means established. Had not so speedy a death followed the expectoration of blood, we should certainly have received more detailed intelligence respecting other hemorrhages; but the malady had no time to extend its effects further over the extremities of the vessels. After its first fury, however, was spent, the pestilence passed into the usual febrile form of the oriental plague. Internal carbuncular inflammations no longer took place, and hemorrhages became phenomena, no more essential in this than they are in any other febrile disorders. Chalin, who observed not only the great mortality of 1348, and the plague of 1360, but also that of 1373 and 1382, speaks moreover of affections of the throat, and describes the back spots of plague patients more satisfactorily than any of his contemporaries. The former appeared but in few cases, and consisted in carbuncular inflammation of the gullet, with a difficulty of swallowing, even to suffocation, to which, in some instances, was added inflammation of the ceruminous glands of the ears, with tumours, producing great deformity. Such patients, as well as others, were affected with expectoration of blood; but they did not usually die before the sixth, and, sometimes, even as late as the fourteenth day. The same occurrence, it is well known, is not uncommon in other pestilences; as also blisters on the surface of the body, in different places, in the vicinity of which, tumid glands and inflammatory boils, surrounded by discoloured and black streaks, arose, and thus indicated the reception of the poison. These streaked spots were called, by an apt comparison, the girdle, and this appearance was justly considered extremely dangerous.