CHAPTER IX.

SMALLPOX AND MEASLES. With our modern habit of seeking out the matter of fact, of going back to the reality and of reconstructing the theory, it is not easy for us to understand how completely the medieval world of medicine was enslaved to authority and tradition even in matters that were directly under their eyes. It was thought a great thing that Linacre, of Oxford, in the first years of the 16th century, and Caius, of Cambridge, some fifty years later, should have gone back to Galen for their authority, passing over the Arabians who had been the interpreters of classical medicine all through the Middle Ages. Their editions of forgotten medical works of the Graeco-Roman school were a step forward in scholarship, and they opened the way to the first-hand observations of disease which really began some hundred years after with the writings of Willis, Sydenham and Morton. But smallpox and measles were not Galenist themes, they were peculiarly Arabian; and the very moderate share that England took in the medical Revival of Learning made no difference to the paragraphs or chapters on those diseases that were circulating in the medieval compends. While the Arabian or Arabistic writers of Spain, of Salerno, and of Montpellier were the depositaries and interpreters of the Galenic teaching, they were also the first-hand authorities upon some matters of specially Arabian experience, of which smallpox and measles were the chief. Whatever was said of those two epidemic maladies abroad, in the systematic works of Gordonio and Gilbert, and in the later compilation of Gaddesden in England, was not only of Arabian origin, but it was all that was known of them. Rhazes, the original Arabic writer on smallpox and measles about the beginning of the 11th century, supplied both the doctrine and the experience. His observations and reasonings, altered or added to by his later countrymen, passed bodily into the medical text-books of all Europe. The interest in the treatise of Rhazes was so great that it was printed in 1766 by Channing, of Oxford, in Arabic with a Latin translation, and in an English translation from the original by Greenhill, of Oxford, in 1847. In the literature we took over smallpox from the Arabians; but had we no native experiences of the disease itself, and, if so, when did it first appear in this country? One can hardly attempt an answer to these questions even now without stirring up prejudice and embittered memories. It has been the fate of smallpox, as an epidemological subject, to be invested with bigotry and intolerance. Whoever has maintained that it is not as old as creation has been suspected in his motives; anyone who shows himself inclined to put limits to its historical duration and its former extent in Britain is clearly seeking to belittle the advantages that have been derived during the present century from vaccination. The wish to establish the antiquity of the smallpox in Europe has been as strong as the wish to overthrow the antiquity of the great pox. While undoubted traces of the latter in early times have been covered over with the generic name of leprosy, the vaguest reference to “pustules” or spots on the skin have been turned by verbalist ingenuity to mean devastating epidemics of smallpox. I am here concerned only with Britain, and must pass over the much-debated reference by Gregory of Tours to epidemics in the 6th century, the period of the Justinian plague. But in England the epidemic which stands nearest in our annals to the great plague of the 6th century, the widespread infection described by Beda as having begun in 664 and as having continued in monasteries and elsewhere for years after, has been claimed by Willan as an epidemic of smallpox[870]. Willan, with all his erudition, was a dermatologist, and acted on the maxim that there is nothing like leather. His contention in favour of smallpox has been referred to in the first chapter, dealing with the plague described by Beda, and need not farther concern us. It is not in England that we find evidence of smallpox in those remote times but in Arabia. Smallpox in the Arabic Annals. For our purpose the evidence on the antiquity of smallpox in China and India may be accepted, and for the rest left out of account. The Arabian influence is nearer to us, and is the only one that practically concerns us. Coming, then, to the history of smallpox in its prevalence nearest to Europe, we find a definite statement of the disease appearing first among the Abyssinian army of Abraha at the siege of Mecca in what was known as the Elephant War of A.D. 569 or 571. The best of the Arabic historians, Tabari[871], writes: “It has been told to us by Ibn Humaid, after Salima, after Ibn Ischâg, to whom Ja‘gûb b. Otha b. Mughira b. Achnas related that one had said to him, that in that year the smallpox appeared for the first time in Arabia, and also the bitter herbs,--rue, colocynth [and another].” The tradition is by word of mouth through several, after the Semitic manner, but it need not on that account be set aside as worthless. So far as concerns the bitter herbs, it is said to be against probability; but as regards the new form of epidemic sickness, there is no such objection to it. The Arabic legend, as given by Tabari is as follows: “Thereupon came the birds from the sea in flocks, every one with three stones, in the claws two and in the beak one, and threw the stones upon them. Wherever one of these stones struck, there arose an evil wound, and pustules all over. At that time the smallpox first appeared, and the bitter trees. The stones undid them wholly. Thereafter God sent a torrent which carried them away and swept them into the sea. But Abraha and the remnant of his men fled: he himself lost one member after another.” In a former passage, the calamity of Abraha is thus given: “But Abraha was smitten with a heavy stroke; as they brought him along in the retreat, his limbs fell off piece by piece, and as often as a piece fell off, matter and blood came forth.” To illustrate this account by Tabari, his recent editor, Nöldeke, cites the following from an anti-Mohammedan poem: “Sixty thousand returned not to their homes, nor did their sick continue in life after their return.” One of the elephants which dared to enter the sacred region is said to have been also wounded and afflicted by the smallpox. In this narrative of Abraha’s disaster, says Nöldeke, there is a mixture of natural causation and of purely fabulous miracle; a real and sufficient account of the cause of the Abyssinian leader’s discomfiture, namely, an outbreak of smallpox, had been blended with legendary tales. That the disease was smallpox is made probable by the continuity of the Arabic name; under the same name Rhazes, the earliest systematic writer, describes the symptoms, pathology and treatment of what was unquestionably the smallpox afterwards familiar in Western Europe. Why it should have originated on Arabian soil in an invading army from Africa, is a question that would require much knowledge, now beyond our reach, to answer conclusively. Theory of the nature of Smallpox. The nature of the disease should, however, be borne in mind always in the front of every speculation as to the origin of its contagious and epidemic properties. It involves no speculative considerations to pronounce smallpox a skin-disease, of the nature of lichen turned pustular. It is a skin-disease first, and a contagious or epidemic malady afterwards; its place among diseases of the skin is indeed fully acknowledged by dermatologists. Apart from its contagiousness it conforms to the characters of other cutaneous eruptions: its outbreak is preceded by disturbed health, including fever; when the eruption comes out the fever is so far relieved; and as in some other eruptions which are not contagious the constitutional disturbance is in proportion to the area of the skin involved. Even the peculiar scars or pits which it leaves behind in skins of a certain texture or in the more vascular regions, such as the face, are not unknown in non-contagious skin-diseases; nor does its other peculiarity, the offensive odour of many pustules, seem unaccountable in a skin-disease native to tropical countries. Eruptions on the skin are in many cases the outcome of constitutional ill-health; for example, the eczema of gout. Also where the whole body is infected, as in syphilis, there are skin-eruptions, which may be pimples (lichenous) or scales, or rashes, or, as in the first great outburst of syphilis, “pustules” so general over the body that those who were casting about for the nosological affinities of the new malady, saw no better place for it than Avicenna’s group of _alhumata_, which included smallpox and measles. That a skin-eruption of the nature of smallpox should have come out as a constitutional manifestation, and that a number of persons should have exhibited it together for the same internal reason, are both credible suppositions, although necessarily unsupported by historic evidence. Let us suppose that the Abyssinian army before Mecca endured some ordinary discomfort of campaigning, that, in the uniformity of their life, numbers together had fallen into the same constitutional ill-health just as numbers together have often fallen into scurvy, and that an eruption of the skin, proper to the tropics, was part of it. What we have farther to suppose is that the constitutional eruption became catching from the skin outwards, so to speak,--that it could be detached from its antecedents in the body, and could exist as an autonomous thing, so that it would break out upon those who had none of its underlying constitutional conditions, but had been merely in contact with such as had developed it constitutionally or from within. Such detachment of a constitutional eruption from its primary conditions is little more than constantly happens when a skin-disease like eczema, or acne, persists long after its provocation, or the disordered health which called it forth, is removed. The inveteracy or chronicity of some skin-diseases is itself a form of autonomy, but a form of it which does not transcend the individual, just as, among infections themselves, cancer does not transcend the individual or propagate itself by contagion[872]. But there exists a closer probable analogy for a secondary eruption becoming a self-existent or independent infective disease. The instance in view is no more than probable, and may easily be disputed by those who have sufficient prepossessions the other way; but there is no theory that suits so well the negro disease of yaws as that it is a somewhat peculiar secondary of syphilis, which is now able to be communicated as an exanthem detached from the primary lesions on which it had depended originally for its existence. All the evidence, historical and geographical, points to the several varieties of the black skin (or yellow skin) as the native tissues of smallpox. It is not without significance that a disease of the negroes which was observed by English doctors not long ago in the mining districts of South Africa led to a sharp controversy whether it was smallpox or not: according to some, it was a constitutional eruption; according to others it was a contagious infection. Such phenomena are not likely to be seen in our latitudes; but the original smallpox itself was not a disease of the temperate zone[873]. I shall not carry farther this line of remark as to the probable circumstances in which a pustular eruption, among the Abyssinians before Mecca, or among other Africans or other dark-skinned races in other places and at other times, had become epidemically contagious in the familiar way of smallpox. One has to learn by experience that there is at present no hearing for such inquiries, because a certain dominant fashion in medicine prefers to relegate all those origins to the remotest parts of the earth and to the earliest ages (practically _ab aeterno_), and there to leave them with a complacent sense that they have been so disposed of. That is not the way in which the study of origins is carried out for all other matters of human interest. Yet diseases are recent as compared with the species of living things; some of them are recent even as compared with civilized societies. Epidemical and constitutional maladies touch at many points, and depend upon, the circumstances of time and locality, and upon racial or national characters. Perhaps their origins will one day be made a branch of historical or archaeological research. European Smallpox in the Middle Ages. The present extensive prevalence of smallpox among the Arabs may or may not date from the Elephant War of A.D. 569. Its prevalence also in Abyssinia, so widely in modern times that almost everyone bears the marks of it, may have no continuous history from the return of Abraha’s expedition. But the history of smallpox in the West comes to us through the Saracens, and there can be no question that the disease is at the present day peculiarly at home in all African countries, and most of all in the upper basin of the Nile, where, as Pruner says, “it appears as the one great sickness[874].” It is a remark of Freind, whose erudition and judgment should carry weight, that “the Saracens first brought in this distemper, and wherever their arms prevailed, this spread itself with the same fury in Africa, in Europe, and through the greatest part of Asia, the eastern part especially[875].” Our inquiry here does not extend beyond England, so that the extremely disputable question of the amount and frequency of smallpox in the European countries conquered or invaded by the Saracens in the Middle Ages need not be raised[876]. So far as concerns England, smallpox was first brought to it, not by the Saracen arms, but by Saracen pens. The earliest English treatise on medicine, the _Rosa Anglica_ of Gaddesden, has the same chapter “De Variolis [et Morbillis]” as all the other medieval compends--in substance the same as in the earlier work of Gilbert, and in all the other Arabistic writings earlier or later. The _Rosa Anglica_ was a success in its day, partly, no doubt, by reason of its style being more boisterous than that of Gilbert’s or Gordonio’s treatises, partly, also, on account of its blunt indecency in certain passages. Guy de Chauliac, of Avignon, one of the few original observers of the time, had heard of the _Rosa Anglica_, and was curious to see it; but he found in it “only the fables of Hispanus, of Gilbert, and of Theodoric,” and he rather unkindly fixed upon it the epithet of “fatuous.” What de Chauliac had probably heard of was Gaddesden’s occasional claims to originality; and these we shall now examine so far as they concern smallpox. One of Gaddesden’s variations from the stock remarks on smallpox is his explanation of why the disease was called variola: it is called variola, says he, because it occurs _in diverse parts of the skin_ (_quia in cute diversas partes occupant_). This is an ingenious improvement upon Gilbert, who says that it is called variola from the variety of colours (_et dicitur variola a varietate coloris_)--sometimes red, sometimes white, or yellow, or green, or violet, or black. Another remark attributed (by Häser at least) to Gaddesden as original, is that a person may have smallpox twice; but Gaddesden, in a later paragraph, shows where he got that from: “And thus says Avicenna (_quarto_ Canonis), that sometimes a man has smallpox twice--once properly, and a second time improperly.” The most famous of Gaddesden’s originalities is his treatment by wrapping the patient in red cloth; for that also Häser ascribes to him. But Peter the Spaniard, the Hispanus of de Chauliac’s reference given above, is before him with the red-cloth treatment also, while he is candid enough to quote Gilbert: “Any cloth dyed in purple,” says Hispanus, “has the property of attracting the matter to the outside.” Gilbert’s reference is as follows: “Old women in the country give burnt purple in the drink, for it has an occult property of curing smallpox. Let a cloth be taken, dyed _de grano_.” Bernard Gordonio, also, says: “Thereafter let the whole body be wrapped in red cloth.” There was probably Arabic authority for that widely diffused prescription, as for all the rest of the teaching about smallpox. But Gaddesden does improve upon his predecessors in boldly appealing to his own favourable experience of red cloth:--“Then let a red cloth be taken, and the variolous patient be wrapped in it completely, as I did with the son of the most noble king of England when he suffered those diseases (_istos morbos_); I made everything about his bed red, and it is a good cure, and I cured him in the end without marks of smallpox.” With reference to this cure, it has to be said, in the first place, that the object of the red cloth was to draw the matter to the surface[877], and that it had nothing to do with the prevention of pitting. The means to prevent pitting was usually to open the pustules with a golden needle; that is the Arabian advice, and all the Arabists copy it. Gaddesden among the rest copies it, but he does not say that he practised it on the king’s son. If he had said so, we might have believed that the disease was actually one bearing pustules which could be opened by a needle. What he says, in the earliest printed text (Pavia, 1492) is that, while the king’s son was “suffering from those diseases,” he caused him to be wrapped in red cloth, and the bed to be hung with the same, and that he cured him without the marks of smallpox. Gaddesden was not altogether an honest practitioner; on the contrary he was an early specimen of the quack _in excelsis_. According to the learned and judicious Dr Freind, “his practice, I doubt, was not formed upon any extraordinary knowledge of his faculty;” and again, “He was, as it appears from his own writings, sagacious enough to see through the foibles of human nature; he could form a good judgment how far mankind could be imposed upon; and never failed to make his advantage of their credulity[878].” The opportunity of diagnosing variola in the king’s son, and of curing it by red cloth, so as to leave no pits, was one that such a person was not likely to let slip. “It is a good cure,” he says; and we may go so far with him as to admit that it must have been impressive to the royal household to have heard some sharp sickness of the nursery called by the formidable name of variola, and to have seen it cured “_sine vestigiis_.” Measles in Medieval Writings. In the writings of the Arabians and of their imitators, the so-called Arabists, measles and smallpox are always taken together. The usual distinction made between them is that _morbilli_, or measles, come from the bile, whereas _variolae_, or smallpox, come from the blood, that the former are small, and that they are less apt to attack the eyes. The reference in Gaddesden is of the usual kind, but it is complicated by the