A Short History of Disease

by Sean Martin

  The work of Vesalius began hammering nails into the coffin of humoural theory (although it took a very long time to die, and was still widespread in the eighteenth century). Surgical and medical schools such as the Royal College of Surgeons in Edinburgh and the Royal College of Physicians in London were founded. William Harvey (1578–1657) discovered the circulation of the blood in 1628, which contributed more nails to the coffin, as did the discovery of the lymphatic system a few years later by Olaus Rudbeck (1630–1702) and Thomas Bartholin (1616–1680). Developments in the manufacture and use of microscopes by Robert Hooke (1635–1703) and Antonie van Leeuwenhoek (1632–1723) effectively invented the science of microbiology. For the first time, human beings were able to see cells and bacteria, which were dubbed animalcules. The founding of the Royal Society in London in 1660 encouraged Hooke, Leeuwenhoek and others to present their findings, and The Society dedicated itself to the furtherance of knowledge.

  Among those invited to present work to the Society was London haberdasher John Graunt (1620–1674). In Natural and Political Observations Made upon the Bills of Mortality (1662), Graunt published his findings on the bills of mortality, which had been published every week in London since 1592. The bills listed the mortality numbers in each parish, and were later modified to include causes of death as well.

  Some need no explanation: Aged, Stillborn, Worms, Cancer, Gangrene and Fistula, Childbed (probably puerperal fever or other complications of birth), Consumption and Tissick (both tuberculosis), Falling Sickness (epilepsy), French Pox (syphilis), Frighted (heart attack?), Grief, King’s Evil (scrofula), Bit with a Mad Dog (rabies), Bloody Flux (dysentery), meagrom (migraine), Made away with themselves, Leprosy, Measles, Palsy and Plague.

  Other people left this world in a slightly more memorable manner: Fainted in Bath, Excessive Drinking, Suddenly (heart attack or perhaps what is now known as Sudden Adult Death Syndrome) or Found Dead in the Streets. And then there are still other causes that are perhaps most memorable of all: Teeth (possibly dental abscesses or oral gangrene), wen (a tumour, so presumably cancer), Rising of the Lights (probably obstructions of the windpipe), Blasted, or Planet Struck (sudden paralysis, or becoming ‘confounded’).

  Writing in his Preface, Graunt said he had ‘found some Truths, and not commonly believed Opinions, to arise from my Meditations upon these neglected Papers.’ In finding truths and not commonly believed opinions, Graunt became one of the first demographers. For the first time, relatively accurate data was available on the prevalence of disease. Gone were the wild estimates, guesswork and exaggerations of mediaeval accounts. Modern public health initiatives all begin with Graunt.

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  In the Americas, so many Indians died from smallpox and other Old World diseases that the Spanish and Portuguese were forced to import slaves from Africa in order to run their plantations and colonies. Black Africans were naturally immune to smallpox, as many had suffered from sickle cell disease (also known as sickle cell anaemia), which was endemic in many parts of Africa. That sickle cell disease gave immunity to smallpox was a biological fluke which condemned millions of Africans to lives of servitude in the New World. In a further horrible irony, freed slaves returning to Africa found themselves susceptible to diseases that they had been immune to – or that did not exist at all – in the New World.

  The East Indies, too, quickly fell within the compass of European imperial ambition. The Portuguese explorer Vasco da Gama sailed for India in 1498, taking syphilis with him. But at sea, another disease manifested itself. Some of da Gama’s crew became lethargic, with their skin drying and tightening, hair knotting into clumps; fresh wounds no longer healed. Then their gums became swollen and purple, and they began to lose their teeth. This latter stage is the classic symptom of scurvy, caused by a deficiency of vitamin C in the diet. In this case, it would have been occasioned by a lack of fresh fruit and vegetables. At its worst, the disease would have caused old fractures to break again, accompanied by tubercular lesions and cardiac haemorrhage.233 Scurvy would blight sailors of all nations for more than two hundred years.

  The English and Dutch conducted experiments into the problem. It was noted that sailors recovered quickly when reaching port and eating fresh fruit and vegetables. However, it was not possible to keep these fresh on long voyages. The Dutch tried planting orchards in their territories on Mauritius and St Helena, and even created gardens on some of their ships. This appears to have had some success in reducing the mortality rate while at sea.234 An English doctor, Edward Ives, who served as ship’s surgeon in the 1740s, tried an alternative idea. Ives persuaded his admiral to carry supplies of the best Devon cider. While these lasted, none of the five hundred men aboard died.235 After numerous such trials and experiments, the English began to provision their sailors with lime juice at the end of the eighteenth century, earning the nickname ‘limeys’.

  Scurvy was not just restricted to the sea. ‘Land scurvy’, or pellagra, afflicted primarily poor city dwellers. The disease was first recorded in the eighteenth century among impoverished farmers of northern Italy and Spain, who had become dependent on maize brought back from the New World. Maize was easy to cultivate, and provided substantial yields. It began to replace barley, wheat and millet. Its economic potential was not lost on Europe’s elites. The Austro-Hungarian royal family, the Habsburgs, ‘actively fostered its production not only because maize provided a staple food for the peasants, but because its greater yields meant larger tithes for the royal coffers.’236 And when said peasants developed pellagra, ‘members of the upper classes... tended either to deny the existence of the disease or to blame its appearance on the inherent moral weaknesses of its victims.’237 Thus, the rich blamed the poor for something the rich themselves were responsible for. But as cities grew in the nineteenth century, pellagra would become one of the least worries of Europe’s poor.

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  The poor were also more likely than the rich to be on the receiving end of harsh treatment if they found themselves detained in an asylum for the mad. The poor would have heavy fetters and chains put on them, as they were ‘fit only for the pauper lunatics: if a gentleman was put in irons he would not like it,’ or so said Thomas Monro (1759–1833),238 head physician at London’s notorious mental asylum, Bethlem Royal Hospital, better known as Bedlam. Indeed, the Board of Governors at Bedlam referred to the patients as ‘prisoners’ and ‘the poor’.

  Conditions had long been harsh: records survive of a sixteenth century patient whose leg was ‘so ulcerated that it is thought it must be cut off’, while another patient complained that ‘her foote was rotten’.239 In 1631, an inquiry found that Bedlam was so underfunded that its patients were close to starvation. By the time Samuel Pepys was writing his celebrated diary, the ‘poor’ were better fed, but had become a tourist attraction: he noted in his Diary for 19 February 1669, ‘All the afternoon I at the office, while the young people went to see Bedlam.’ An entry fee of one penny would admit the curious, where they could wander at will, looking at the patients as if they were specimens in a zoo.

  In 1699, the writer Ned Ward (1667–1731) published his account of just such a day out:

  We heard such a rattling of chains, drumming of doors, ranting, hollering, singing and rattling, that I could think of nothing but Don Quevedo’s Visions [possibly a reference to Francisco de Quevedo’s 1608 satire The Dream of Hell] where the damn’d broke loose, and put Hell in an uproar.240

  Ward witnessed one of the ‘shatter-brained fraternity’ expose herself to a young girl, shouting, ‘I’ve got hair where you’ve got none’, and narrowly escaped being soaked in urine by one patient, the ‘bread and cheese’ man, who took great delight in hurling the contents of his chamber-pot at visitors. Another inmate didn’t seem to use a chamber pot at all, as he ‘smelled of urine and ran round his cells clapping his hands and shouting “halloo, halloo, halloo…”’241 In art, Hogarth’s A Rake’s Progress No 8: In the Madhouse (1732–3) and Goya’s Yard with Lunatics (17
93–4) and The Madhouse (1812–19) captured the desperate condition of the ‘distracted’.

  Such treatment reflected the fact that the mad were down in the sewers of public opinion, along with lepers, prostitutes and the disabled. No one knew what caused madness. For centuries it had been on the borderlands of the demonic, with exorcism being the principal remedy. If demons weren’t responsible, then an imbalance of the humours was to blame, or the influence of the moon. By the nineteenth century, the etiology had shifted away from supernatural causes to the relatively bland, not to say downright eccentric: domestic disturbances and disappointed love – the latter affecting women in particular – were thought to have made more people ‘nervous’ ‘than the sword has slain’. Other potential causes of madness were thought to include ‘mistaken perceptions of real religion’, ‘hard, intense and long-continued studies’, ‘the fearful associations of being awoke from sound sleep while the house is on fire’, ‘blows on the head’ and onanism.242 The French doctor Philippe Pinel (1745–1826) believed that physical factors – such as ‘an organic lesion of the brain’ – caused insanity, or that emotional disorders might play a part.243

  There was no agreement on treatment. The practice of trepanation – drilling a hole in the skull – is thought to be one of the oldest methods of controlling mental illness; skulls from the Bronze Age have been found bearing the telltale holes and cracks of the trepanner’s art. This rather extreme method was still being practised during the Renaissance, as evidenced by Hieronymus Bosch’s painting, The Extraction of the Stone of Madness (c. 1494). From the seventeenth century onwards, institutionalisation was generally seen as the way to proceed. The prominent London physician Thomas Willis (1621–75) advocated administering regular thrashings to patients, while Thomas Monro admitted before a government enquiry in 1815 that at Bedlam, ‘We apply generally bleeding, purging and vomit’.244 Others advised drugs such as opium, concoctions of agrimony, ivy and vinegar, or shock treatments such as throwing the lunatic into a river. A cold bath would suffice if there was no river nearby.

  This was all far behind what was going on in the Ottoman Empire. In the hospital founded in Edirne by Sultan Bayezid II (1481–1512), fragrant scents were employed to calm patients. Flowers were thought to affect the humours. Violets, for instance, were said to have a cool and moist temperament, and therefore were good for treating the opposite qualities of yellow bile. This didn’t always work: the flowers used ‘as a type of olfactory therapy’ were sometimes trampled on by the patients, or simply eaten.245 Other forms of quite humane-seeming therapy were tried, including the use of theatrical performances. The Ottoman Turk writer and traveller Evliya Chelebi visited Edirne in 1651, where he noted music was also being used, ‘and many of the insane were reported to have been relieved by this “nourishment of the soul”’.246

  Things had not always been so progressive in the Muslim world. The hospital in Damascus that was treating insane patients by 1185, where, according to the Muslim traveller Ibn Jubayr, there was ‘a system of treatment for confined lunatics, and they are bound in chains.’247 The Berber writer and diplomat Leo Africanus (c. 1494 – c. 1554) visited the hospital in Fez and noted conditions as bad as those at Bedlam: ‘The walls of their rooms were strengthened with heavy beams of wood and iron. The person who was in charge of feeding them constantly carried a whip, and when he saw an agitated patient, he administered a good thrashing.’248 The tradition of going to look at the mad also existed. In ‘The Three Madmen’s Tale’ from The Book of the Thousand Nights and One Night, we read of this:

  ‘What do you say to a visit to the maristan [asylum], my lord? We have often spoken of exploring a house of fools together, but we have never done so yet. To my way of thinking, the mad have a more subtle understanding than the sane. They behold differences and affinities which are hidden from common men, and are often visited by strange visions.’249

  The ‘differences and affinities which are hidden from common men’ that some asylum patients were privy to was not necessarily madness. In the early sixteenth century, Sir Thomas More described one patient who was in Bedlam because he had ‘fallen in to ye frantike heresyes’250 while Ned Ward met a man on his 1699 visit who spouted anti-monarchist views from the confines of his cell. When Ward informed the man he was committing treason by saying such things, the man surprised Ward by agreeing with him, and offered a lucid defence of his position:

  ‘Truth is persecuted everywhere abroad, and flies hither for sanctuary, where she sits as safe as a knave in a church, or a whore in a nunnery. I can use her as I please and that’s more than you dare do. I can tell great men such bold truths as they don’t love to hear, without the danger of a whipping-post.’251

  As Bedlam historian Paul Chambers notes, ‘The man was quite correct. So long as he was classified as mad, he was free to express his anti-establishment views without fear of repercussion. Should he ever be declared sane and released then these same views would more than likely land him in prison or the pillory.’252 Chambers speculates that the anti-monarchist might have been Richard Stafford, a fervent Jacobite who was admitted to Bedlam in 1689. This was a quicker way of getting him off the streets, where he had been ‘dispersing books and pamphlets full of Enthusiasm and Sedition’,253 than taking him to court. As the French philosopher Michel Foucault argued, the growth in asylum building from the seventeenth century onwards in Europe was a symptom of the ruling elites’ need to control their populations, freethinking in particular.

  Epileptics could also find themselves in Bedlam and similar institutions if there was no one to look after them in the outside world. As with the ‘distracted’, early mental asylums didn’t really know what to do with epileptics, given that no one really knew what caused the disease. It was generally best to lock them up out of sight, as some thought epilepsy might be psychologically contagious: merely seeing someone have a fit might bring one on in the observer.254

  Epilepsy was long associated with ideas about demonic possession and malign astrological influences. The Arabs referred to it as the ‘Divine Disease’, echoing the ancient Babylonian belief that epilepsy was caused by the ‘touch of a god’. From the early Middle Ages epilepsy had been associated with madness. Isidore of Seville, writing in the seventh century, referred to epileptics as lunaticus. Sometimes these ‘lunatics’ were thought to have prophetic visions, and enjoyed the status of a holy fool.

  Despite the longstanding supernatural associations, some medical authorities had surmised quite early on that epilepsy was a ‘disease of the brain’. Despite its title, the Hippocratic text On the Sacred Disease argues that epilepsy had natural causes and should be treated accordingly, with a regimen based on diet and exercise. There is some evidence that, when trying to ascertain the causes of epilepsy, certain later Greek physicians – Herophilus (335–280 BC), Erasistratus (304–250 BC) and Asclepiades of Bithynia (c.124–40 BC) – ‘tended to think in terms of the brain and nervous system’.255 These early intimations of epilepsy as a neurological condition were finally confirmed in the nineteenth century. But after Soranus of Ephesus (fl. second century AD), who was ‘perhaps the last for some time to think about epilepsy in this way’, came Galen and humoural theory, which influenced nearly all subsequent writers and physicians until the nineteenth century.

  However, epilepsy retained its stigma. On the Sacred Disease is critical of the superstitions surrounding epilepsy, such as the efficacy of avoiding baths, eating goat meat or wearing black in curing the disease. Those who advocated such things were, according to Hippocrates, no better than ‘conjurors, purificators, mountebanks, and charlatans’. Another widely held belief was that epilepsy could be cured by drinking fresh human blood. In Roman times, epileptics were known to enter the arena to drink blood from gladiators’ wounds. The historian of epilepsy, Owsei Temkin, might have been thinking of this practice when he wrote, ‘To the ancients, the epileptic was an object of horror and disgust and not a saint or prophet as has sometimes been c
ontended.’256 Epilepsy – like madness – was seen as making a person unclean, and Romans had the custom of spitting whenever they saw an epileptic, which was thought to keep the demon that caused the disease at bay. They also avoided drinking from the same cups as epileptics, and eating from the same platters. Like leprosy, epilepsy was the disease of the sinner.

  5

  Early Modern to 1900

  Returning one evening, somewhat later than usual, to my own house, my attention was attracted, just as I entered the porch, by the figure of a man reclining against the wall at a few paces distant. My sight was imperfectly assisted by a far-off lamp; but the posture in which he sat, the hour, and the place, immediately suggested the idea of one disabled by sickness. It was obvious to conclude that his disease was pestilential.

  So begins Arthur Mervyn, the novel by Charles Brockden Brown, first published in 1799–1800. The pestilential disease which the man on the porch – the hero, Arthur Mervyn – is suffering from is yellow fever. A major epidemic decimated Philadelphia in 1793, which forms a major part of the plot. (Indeed, the novel’s subtitle is Memoirs of the Year 1793.) Arthur describes the scene in the Welbeck mansion:

  I wandered over this deserted mansion, in a considerable degree, at random. Effluvia of a pestilential nature assailed me from every corner. In the front room of the second story, I imagined that I discovered vestiges of that catastrophe which the past night had produced. The bed appeared as if some one had recently been dragged from it. The sheets were tinged with yellow, and with that substance which is said to be characteristic of this disease, the gangrenous or black vomit. The floor exhibited similar stains...

  The door opened, and a figure glided in. The portmanteau dropped from my arms, and my heart’s blood was chilled. If an apparition of the dead were possible, (and that possibility I could not deny,) this was such an apparition. A hue, yellowish and livid; bones, uncovered with flesh; eyes, ghastly, hollow, woe-begone, and fixed in an agony of wonder upon me; and locks, matted and negligent, constituted the image which I now beheld. My belief of somewhat preternatural in this appearance was confirmed by recollection of resemblances between these features and those of one who was dead.257