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 introduction of a third term, _punctilli_, which Gruner, however, takes to be merely a synonym for _morbilli_. As Gaddesden’s passage is of some importance for the history of the familiar name of the disease in England, I shall translate it at length, so far as it can be made into sense:--

“Variolae are so called, as if variously choosing the skin itself, because in the skin they occupy divers parts, by apostematising and infecting; they are caused by corruption of blood, and therein they differ from morbilli and punctilli.

Morbilli are small apostemata in the skin generated of bile; and they are a diminutive of apostematous diseases because they occupy less space by reason of the sharpness of choleric matter. They are in fact variolae of choleric matter, and the smallest of pustules. But punctilli are infections commonly sanguineous, as if they had arisen from a fleabite, only they remain continually. And punctilli are of two kinds, large and small. Of the small I have already spoken [under the name of morbilli?]. But the large are broad, red and opaque infections in the legs of poor and wasting persons, (_pauperum et consumptuorum_), who sit as if continually at the fire without boots; and they are called in English _mesles_[879].”

The rest of Gaddesden’s chapter on smallpox and measles contains nothing that is not to be found in Avicenna or in any medieval compend on medicine. But the passage quoted is of interest as using the old word “mesles” to mean one of the two forms of _morbilli_ or _punctilli_. We are here enabled to see a little way into the confusion of mind which attended the medievalists in their verbalist dealing with disease. The syntax of Gaddesden’s sentence implies that the broad, red and opaque infections on the legs of poor and wasted persons were called in English _mesles_. In other writers, both before and after his date, the name of mesles or mesels or meseals was given, not to a form of disease, but to a class of sufferers from disease. It is the name applied to the inmates of leper-houses by Matthew Paris (circa 1250)--_miselli_ and _misellae_, being diminutives of _miser_[880]. It is the word used for the same class in the Norman-French entries in the Rolls of Parliament in the reign of Edward I. fixing the taxation of leper-houses: if the head of the house was himself a _meseal_, the hospital was to pay nothing, but if the head were a whole man, the hospital had to pay[881]. The same use of mesles, as meaning the leprous, in the generic sense, occurs several times in the 14th century poem, ‘The Vision of Piers the Ploughman[882].’ Thus, Christ in His ministrations,

“Sought out the sick and sinful both, And salved sick and sinful, both blind and crooked; And comune women converted, and to good turned. Both meseles and mute, and in the menysoun bloody, Oft he heled such. He ne held it for no mystery, Save tho he leched Lazar that had ylain into grave.”

Or again:

“Ac old men and hore that helpless ben of strength, And women with child that worche ne mowe, Blind and bedred and broken their members, That taketh their mischief mekely, as meseles and other.”

It is this old English word “mesles,” meaning the leprous in the generic sense, that Gaddesden brings into his Latin text in connexion with _morbilli_ (or _punctilli_). It is useless to look for precision in such a writer; but if his introduction of “mesles” in the particular context mean anything at all, it means that the English word represented a variety of _morbilli_,--the large, broad and opaque variety. That it should have occurred to him to bring these blotches or spots on the legs of poor people even remotely into relation with the _morbilli_ of the Arabians, probably means that Gaddesden had a merely verbal acquaintance with the latter, or that he knew them only in books. It is certainly improbable that anyone, even in the Middle Ages, who had ever seen a case of measles should bracket that transitory and insubstantial mottling of the skin, with the large, broad and “obscure” spots (or nodules, or what else) on the legs of poor and wasted persons, which were called, in the vernacular, mesles. But Gaddesden, though a verbalist and a plagiary, was a great name in medicine, a name usually joined (as in Chaucer) with more solid reputations than his own. If he identified “mesles” with a variety of _morbilli_ (which variety no one but himself seems to have heard of), it was an easy transition for the name in English usage to become what it now is, measles meaning _morbilli_, in the correct and only real sense of the latter[883].

History of the name “Pocks” in English.

Gaddesden’s case of _variola_ which he cured without pitting by means of red cloth stands alone in English records until the 16th century; probably he was as little able to diagnose variola as _morbilli_, and it is more than probable that he would not have scrupled to call some infantile malady by the book-name _variola_, on the principle of “omne ignotum pro terribili,” when there was anything to be gained by so doing. There is no independent evidence that smallpox or measles existed in England in the 14th and 15th centuries. There are extant various medieval prescription-books, in which remedies are given for all the usual diseases. If the name of _variola_, or any English form of it, occur therein, we should draw the same inference as from the prescriptions for maladies of children such as “the kernels,” and “the kink” (or whooping-cough)[884]. In the Anglo-Saxon “leechdoms,” which have been collected in three volumes, the word _poc_ occurs once in the singular in the phrase “a poc of the eye” (probably a hordeum or sty of the eyelid), and once in the plural (_poccan_) without reference to any part of the body and with no indication that a general eruption was meant. Willan, indeed, has found in a manuscript of uncertain date a Latin incantation against disease, in which the words _lues_, _pestis_, _pestilentia_, and _variola_ occur; at the end of it is written in Anglo-Saxon an invocation of certain saints to “shield me from the _lathan poccas_ and from all evil[885].” This looks as if _poccas_ had been the Anglo-Saxon translation of _variola_. But it remains to be seen in what sense the word “pokkes” was used in the earliest English writings.

In the ‘Vision of Piers the Ploughman’ (passus XX) the retribution of Nature or “Kynde” upon the wickedness of the times is thus mentioned:

“Kynde came after with many keen sores, As pokkes and pestilences, and much people shent; So kynde through corruptions killed full many.”

In the lines immediately preceding there occur some other names, equally generic:

“Byles and boches and brennyng agues Frensyes and foul evils, foragers of kynde.”

“Boche” is botch,--the name given to the plague as late as the Stuart period, from its chief external sign, the bubo; and “byles” is merely the Latin _bilis_ = _ulcus_. “Pokkes” may be the Anglo-Saxon word; but it is known that many of Langland’s colloquialisms are of Norman or French origin, and in that language there is a term _poche_, which is not far from the English “boche.” Whether “poche” be the same as “boche” or not, “pokkes and pestilences” may be taken to be synonyms for “byles and boches.” The generic or elastic use of such terms received a striking illustration in 1528, when spotted fever (typhus), perhaps mixed with plague, became exceedingly common among French and Spanish troops. Among the French the disease was called _les poches_ and among the Spaniards _las bubas_[886], although both names had been assigned to syphilis at the time of its epidemic outburst in the end of the 15th century. In those times diseases were called by their external marks; so that diseases essentially most unlike, but having certain spots, or blemishes, or botches, or pustules of the skin in common, were called by a common name. The plague itself was known by certain spots on the breast or back called tokens: hence the figure of John Stow and others that “many died of God’s tokens.”

There was certainly laxity of naming to that extent in the case of modern languages. As to Willan’s inference from the medieval incantation, it is by no means clear that _variola_ in medieval Latin may not have been used generically also; although, in the school of Salerno it appears to have had its meaning fixed, in the Arabic sense of smallpox, from the time of Constantinus Africanus, who introduced the teaching of Bagdad into that school about the year 1060.

The next use of “pokkes” that I have found is in a manuscript chronicle of England down to the year 1419[887], one of the series known as the chronicle of the Brute (from its commencing with the mythical landing of Brutus in England after the siege of Troy); this manuscript, known as the “Fruit of Times,” was afterwards printed at the St Albans press about 1484[888], the history being carried down to Edward IV., and the passage in question reproduced exactly as it stands in the handwriting. Under the 40th year of Edward III. (1366) there is the following entry:

“Ther fell also such a pestalence that never none such was seen in no man’s tyme or lyf, for many men as they were gone to bede hole and in gude poynte sodanly thei diede. Also that tyme fell a seknes that men call ye pokkes, slogh both men and women thorgh ther enfectyne.”

It is clearly the same passage that occurs condensed in the chronicle of William Gregory, mayor of London, which was written probably in 1451-52[889]. Under the 40th of Edward III., after referring to a “grete batille of sparows” just as the earlier chronicle does, he proceeds: “Also the same yere men and bestys were grettely infectyd with pockys, wherfore they dyde, bothe men and bestys.” The variation of “men and beasts,” instead of men and women, is curious, and suggests that there may have been a common source for the story. The chronicle contemporary with 1366, which is of best authority, was that kept at St Albans Abbey; but it gives nothing under that year. Shortly after 1361, however, and probably about 1362 or 1363 it has a singular entry, which may have been the source of these references to “pockys.” The Latin may be translated thus: “Numbers died of the disease of lethargy prophesying troubles to many; many women also died of the flux; and there was a general murrain of cattle[890].” Here we have men, women, and cattle; also lethargy, flux, and murrain; and it is conceivable that later compilers of English chronicles may each have used this contemporary Latin entry of composite events to put their own gloss upon it, or to amplify the history into what each conceived to be the probable meaning. But the most singular enlargement was that made by Holinshed in his chronicle of 1577. Having copied word for word, sparrows and all, the entry under the year 1366 in the “Fruit of Times” (as printed at St Albans about 1484), he takes leave to amend the sense in the part that chiefly concerns us--he changes “pockys” into “smallpocks,” and “men and women” into “men, women, and children[891].” Holinshed was dealing with an event two hundred years before his own time, and had no more first-hand knowledge of it than we have; but his authority has been accepted for the fatal prevalence of smallpox in 1366 by modern writers on the history of that disease, such as James Moore[892], who have not sought for the contemporary authority nor exercised a critical judgment upon the lax ways of verbalist compilers. Thus is history made--but not so easily unmade.

One other reference to “pockys” has to be noticed before we leave the philological part of the subject and come to the unambiguous history of the realities. Fabyan, in his _Chronicle_ written not long before his death in 1512, says that Edward IV. during an expedition to the Scots Marches “was then vysyted with the syknesse of pockys[893].” It is futile to conjecture what the king’s illness may really have been. The word in Fabyan’s time had already acquired a technical sense, which it has ever since retained; but that well-understood meaning was some twenty years later than the year 1474 (although the disease itself doubtless existed all through the Middle Ages); while, in its earlier generic sense, as in the ‘Vision of Piers the Ploughman,’ it seems to have meant botches or other tokens of pestilential disease. In a Latin glossary of English words, published a hundred years after[894], “a pocke” is still defined as _phagedaena_, and “the French pocke” as _morbus Gallicus_, while “smallpox” is not given at all.

Smallpox in England in the 16th Century.

The earliest references to smallpox in England, apart from the probably incorrect one by Gaddesden early in the 14th century, occur in letters of the years 1514 and 1518. Another letter of 1514 will serve to bring out the ambiguity of the names given to diseases at the time. On June 30, 1514, Gerard de Pleine writes from London to Margaret of Savoy that he had been asked by the bishop of Lincoln why the marriage between the princess Mary and Louis XII. had been broken off (it took place shortly after), and by another great peer whether Louis XII. “avoit eu les pocques,” which last sentence has a marginal note in the printed collection of letters: “c’est la petite verole[895].” But _les pocques_ in a letter written from London in 1514 did not mean the smallpox. In a letter of March 3, 1514, Peter Martyr writing in Latin from Valladolid to Ludovico Mendoza, says that the King of England has had a fever, and that the physicians were afraid it would turn to the pustules called _variolae_, but he is now well again and rises from his bed[896]. This illness of Henry VIII. happened at Richmond previous to 7th February. Although in the letter quoted there was only a fear that the illness might have turned to the pustules called smallpox, yet in the instructions of Henry VIII. to Spinelly, English ambassador in the Low Countries, sent in February, the twelfth item instructs him to say that the English king has lately been visited by a malady “nommée la petitte verolle[897].”

Four years after, on July 14, 1518, Pace writes to Wolsey from Wallingford, where the court then was, that the king was to leave next day for Bisham “as it is time; for they do die in these parts in every place, not only of the small pokkes and mezils, but also of the great sickness[898].”

These are the earliest known instances of the use of the words _pocques_, _variola_, _petite verolle_, “small pokkes and mezils,” as applied to

## particular cases of sickness, in correspondence from or relating to

England. The remarks to be made upon the early usage are: first, that the word _pocques_, as used by one writing in French from London in 1514, did not mean smallpox, but pox; second, that the first authentic mention of smallpox happens to have been in the French form--“une maladie nommée la petitte verolle;” third, that, in the political gossip of the time the opinion of the physicians regarding the illness of the young king is given as of a fever which they feared might have turned to the pustules called “_variolae_;” and fourthly, that in the very first mention of the disease _variola_ by an English name “small pokkes,” the name is modelled on the French, being coupled with the old English name “mezils.” It is impossible to infer from these references anything as to the amount of smallpox in England at the time, or even to be sure of the correctness of the diagnosis. The lax usage as between “pox” and “smallpox” is shown in a book of the year 1530 called ‘Prognosticacions out of Ipocras and Avicen,’ in which a brief reference to _variola_ in the Latin original is translated “to prognosticate of the pockes.”

In Sir Thomas Elyot’s _Castel of Health_, published in 1541, children after their first infancy are said to suffer from a number of maladies, and in “England commonly purpyls, meazels and smallpockes.” That is perhaps the first use of the terms in a systematic work on medicine, not indeed by one of the faculty, but by a layman. About the same time we hear of smallpocks in an infant of noble family: a letter of May 26, 1537, from Charles duke of Suffolk to Cromwell, written from Hoxun in Suffolk, excuses his not repairing to Lincolnshire, as the king had ordered, on the ground that “his son fell sick of the smallpox and his wife of the ague[899].” “His son” was Henry Brandon, born September 18, 1535, so that he was then an infant of some twenty months; he is the same that died, with his younger brother, of the sweating sickness in July 1551.

The reference to smallpocks and meazels by Elyot in his _Castel of Health_ is repeated in the almost contemporary _Book of Children_ by Thomas Phaer. Whether Phaer translated that also “out of the French tongue” as he did the _Regiment of Life_, with which it is bound up in the edition of 1553, we have nowhere any information. In a list of forty infirmities of children, the 32nd in order is “small pockes and measels.” A later passage in the _Book of Children_ shows how much, or how little, intelligent meaning Phaer attached to these terms: “Of smallpockes and measels. This disease is common and familiar, called of the Greeks by the general name of exanthemata, and of Plinie papulae et pituitae eruptiones. It is of two kinds:--varioli, ye measils; morbilli, called of us ye smal pocks. They be but of one nature and proceed of one cause. The signs of both are so manifest to sight that they need no farther declaration;”--but he does add some signs, such as “itch and fretting of the skin as if it had been rubbed with nettles, pain in the head and back etc.: sometimes as it were a dry scab or lepry spreading over all the members, other whiles in pushes, pimples and whayls running with much corruption and matter, and with great pains of the face and throat, dryness of the tongue, hoarseness of voice, and, in some, quiverings of the heart with sownings.” He then gives the four causes, three of them being intrinsic states of the humours, and the fourth “when the disease commenceth by the way of contagion, when a sick person infecteth another, and in that case it hath great affinity with the pestilence.” The treatment is directed towards bringing out the eruption; all occasions of chill are to be carefully avoided. More special directions are given for cases in which “the wheales be outrageous and great;” also, “to take away the spots and scarres of the small pockes and measils,” a prescription of some authors is given, to use the blood of a bull or of a hare.

The whole of Phaer’s section on smallpox and measles bears evidence of a foreign source, namely the same stock chapter from which Kellwaye drew most of his section upon the same two diseases appended to his book on the plague in 1593. Not only does Phaer speak of smallpox and measles conjointly as leaving spots and scars, but he actually renders _variolae_ by measles, and _morbilli_ by smallpox. Phaer was more of a literary compiler than a physician with original knowlege of diseases and their pathology. But he is not singular among the Tudor writers in taking measles to be the equivalent of _variolae_. William Clowes, of St Bartholomew’s Hospital, one of the most experienced practitioners of his time, does the same. His _Proved Practice for all Young Chirurgeons_ has an appendix of Latin aphorisms “taken out of an old written coppy,” to each of which aphorisms Clowes has added an English translation: in the aphorism on _variolae_, that term is translated “measles,” the name of “smallpox” nowhere occurring in the book. Clowes’s translation is exactly in accordance with the English-Latin glossary of the time by Levins (1570). Levins was an Oxford fellow who had graduated in medicine and afterwards become a schoolmaster, just as Cogan, of _The Haven of Health_, had done. He wrote the _Pathway of Health_, and also compiled the _Manipulus Vocabulorum_. His definitions in the latter may be taken, therefore, to stand for the medical usage of the time. In this glossary, “ye maysilles” is rendered by _variole_, while the name of “smallpox” is omitted altogether, “a pocke” having its Latin equivalent in _phagedaena_, and “ye French pocke” in _morbus Gallicus_. In the Elizabethan dictionary by Baret, “the maisils” is defined as “a disease with many reddish spottes or speckles in the face and bodie, much like freckles in colour;” and that was the disease which the English profession then understood to be the same as the _variolae_ of medieval writers.

I leave readers to draw their own conclusions, whether there was much or little smallpox or measles in England in the Tudor period. They may be reminded that Pace, dean of St Paul’s, in a letter from Berkshire in 1518, asserts the fatal prevalence of “smallpox and mezils,” and that the duke of Suffolk called the illness of his infant son by the name of smallpox in 1538. They may be farther helped to a conclusion by the following curious instance which has been recorded by John Stow.

Among the miscellaneous collections of that antiquary preserved in the Lambeth Library[900], there is a narrative of the troubled conscience of Master Richard Allington, esquire, a gentleman who appears to have lent money at high interest. Believing himself to be dying on November 22, 1561, he summoned to his bedside at eight in the evening the Master of the Rolls (“Sir John of the Rolls”), two doctors of the law and two other lawyers.

He began: “Maisters, seinge that I muste nedes die, which I assure you I nevar thought wolde have cum to passe by this dessease, consyderinge it is but the small pockes, I woulde therefore moste hertely desyre you in the reuerence of God and for Christes passions sake to suffer me to speake untyll I be dede, that I may dyscharge my conscens” etc. He then explains that “no man had so especial tokens of God’s singular grace, and so litele regarded them as I have done,” and goes on to mention particular acts of usury and to offer restitution to the amount of some hundred pounds or more. It had occurred to him to do so the second night after he fell sick, being in perfect memory lying in his bed broad awake, but with puppets dancing around him. After entrusting the lawyers at his bed side with these restitutions, he asked the Master of the Rolls to read to him certain of the penitential Psalms which the sick man had selected as appropriate. “And then he thought he should have died, but then broth being given unto him, he revived again and fell to prayer and gave himself wholly to quietness;” and there the narrative ends.

It appears from a reference in Stow’s _Survey of London_ that he did die in 1561, and that his widow was left well off: for she afterwards built one of the finest of the new houses that were now beginning to line the highway of Holborn almost as far out as St Giles’s in the Fields.

This is the first recorded case of smallpox in English. According to the patient’s own view, smallpox was not usually a formidable disease, nor does it appear that the Master of the Rolls and four other eminent lawyers (Dr Caldwell, Dr Good, Mr Garth, and Mr Jones) had been apprehensive of catching it. One finds no other evidence of the existence of smallpox in London or elsewhere in England until it is mentioned in a letter of 1591 and in the essay of Kellwaye, 1593, which asserts the occurrence of “smallpox and measles” in almost the same language as Phaer’s earlier _Book of Children_ and for the most part under the same foreign inspiration. From Scotland we have a single reference in Dr Gilbert Skene’s essay on the plague, published in 1568, from the terms of which one may suppose that he is giving his own experience. The season, he says, will sometimes foretell the plague, as well as other diseases:

“Siclyk quhen pokis or sic pustulis are frequent, not onlie amangis barnis, but also amangis those quha be of constant or declynand aige--greit frequent south and south-vest vyndis.” In a similar passage on the previous page he couples “pokis, mesillis and siclike diseisis of bodie[901].”

In a letter of August 26, 1591, written to a member of queen Elizabeth’s court, it is said: “Hir Higness wold you should remove from that place where the smalle pocks were, to take the fresh and clere ayre, the better to purge ye from the infection[902].”

In 1593 we come to the first systematic English essay on the disease, appended to the treatise on the plague by Simon Kellwaye[903]. The author is otherwise unknown as a medical writer, but he is commended in a preface by George Baker, a court surgeon, for his “good and zealous intent and sufficiencie in his profession.” In appending an essay on smallpox to a treatise on the plague he follows the example of the Salernian treatise of Alphanus, which also affords him most of his systematic materials in both diseases, filtered through Ambroise Paré and other writers. Kellwaye claims, however, to have incorporated native experience: “which work I have collected and drawn from sundry both auncient and later writers, the which being shadowed under the calm shroud of auncient consent and strengthened with the abundant sap of late experience (as well mine own as others) I here present the same.” In the treatise on the plague (fol. 2) he mentions smallpox as among the forerunners or prognostics of that disease:

“When the smalle poxe doth generally abound both in young and old people.” In the separate essay on the smallpox (fol. 38), its interest is again that of a forerunner or sequel of the plague, according to the foreign teaching of the time:

“For that oftentimes those that are infected with the plague are in the end of the disease sometimes troubled with the smallpockes or measels, as also by good observation it hath been seen that they are forerunners or warnings of the plague to come, as Salius and divers other writers do testify, I have thought good and as a matter pertinent to my former treatise” etc.

He proceeds: “I need not greatly to stand upon the description of this disease because it is a thing well known unto most people.” It begins with a fever; then shortly after there arise small red pustules upon the skin throughout all the body, which come forth more or less intermittently; “In some there arise many little pustules with elevation of the skin, which in one day do increase and grow bigger, and after have a thick matter growing in them, which the Greeks call exanthemata or ecthymata; and after the Latins variola, in our English tongue the smallpockes; and here some writers do make a difference betwixt variola and exanthemata: for, say they, that is called variola when many of those pustules do suddenly run into a clear bladder, as if it had been scalled, but the other doth not so; yet are they both one in the cure.” He recognizes the contagious property of the disease, calling it “hereditable:” “For we see when one is infected therewith, that so many as come near him (especially those which are allied in the same blood) do assuredly for the most part receive the infection also.” His _Practica_ are taken almost entirely from the Arabian writers, as filtered through Gaddesden, one of them being the prevention of pitting by opening the pocks with a gold pin or needle. He had heard, however, “of some which, having not used anything at all, but suffering them to dry up and fall of themselves without picking or scratching, have done very well, and not any pits remained after it.” He then refers to complications, such as ulcerations of the skin, soreness and ulcerations of the mouth (_aphthae_), soreness of the tonsils, and glueing together of the eyelids, all of which are stock paragraphs in the foreign writers of the time and are probably transferred from the latter. Also he goes a considerable way towards the separation of measles from smallpox, which was not fully effected in England until the century following: “What the measels or males are:--many little pimples which are not to be seen but only by feeling with the hand are to be perceived; they do not maturate as the pocks doth do, nor assault the eyes” etc.

About ten years after Kellwaye’s essay, there began, in 1604, the classification of the deaths in London by the Company of Parish Clerks: but it was not until 1629 that their weekly and annual bills were regularly printed. In the first printed bills, “Flox, smallpox and measles” appear as one entry. The meaning of “flox” seems to be explained by Kellwaye’s remark: “And here some writers do make a difference betwixt variola and exanthemata; for, say they, that is called variola when many of those pustules do suddenly run into a clear bladder as if it had been scalled, but the other doth not so.” That is the distinction between confluent smallpox and discrete; and the most probable explanation of “flox” is that it stands for the confluent kind, or for the pustules that run together into a clear bladder.

Smallpox in the 17th Century.

The gradual rise of smallpox to prominence in England about the end of the Elizabethan period and in the first years of the Stuarts cannot fail to strike anyone who is occupied with the English records of disease as a whole. Smallpox and measles may have been, and almost certainly were, observed in England in the earlier part of the 16th century; but they make no such figure in the records, domestic and other, as they do from the beginning of the 17th century onwards. Perhaps the first mention of smallpox, in English literature proper, occurs in a collection of lyrical poems published in 1602[904]. In some verses “Upon his Ladies sicknesse of the Small Pocks,” the poet, Th. Spilman, apostrophises the “cruel and impartial sickness” and asks,--

Are not these thy steps I trace In the pure snow of her face?

Th’ heavenly honey thou dost suck From her rose cheeks, might suffice; Why then didst thou mar and pluck Those dear flowers of rarest price?

In two letters of Dr Donne, dean of St Paul’s, written probably a few years before his death in 1631, reference is made to the smallpox in London. In the one he says:

“At my return from Kent to my gate, I found Peg had the pox: so I withdrew to Prickham and spent a fortnight there. And without coming home, when I could with some justice hope that it would spread no farther amongst them (as I humbly thank God it hath not, nor much disfigured her that had it), I went into Bedfordshire” etc.

This dread of smallpox infection is quite unlike anything that we meet with in the earlier 16th-century domestic memorials; in them it is only the infection of the plague that comes in. Donne’s other reference is to the sickness of my lord Harrington: “a few days since they were doubtful of him; but he is so well recovered that now they know all his disease to be the pox and measles mingled[905].”

Cases of smallpox among the upper classes are occasionally mentioned in the letters written by Chamberlain to Carleton in the reigns of James I. and Charles I.[906]. On December 17, 1612, “The Lord Lisle hath lost his eldest son, Sir William Sidney, by the smallpox, which were well come out.” On December 31, the same year, Carleton, writing from abroad, mentions that the duke of Mantua had died of the smallpox about three weeks since, of which he buried his only son not three weeks before. Also on December 31, Chamberlain writes to him, that the Lady Webbe was sick of the smallpox, of which, he says in another letter, she died: “She was grown a very proper woman, but loved the town too well, which in a short time would have drawn her and her husband dry as well in purse as in reputation.” It is the year 1614 that is given (by Horst) as the worst season of smallpox all over Europe and the East; England is mentioned by the foreign writer as among the countries affected, but there is no trace of an epidemic in our own records. On April 20, 1616, Chamberlain mentions the case of the duke of Buckingham, the favourite; “he hath been crazy of late, not without suspicion of the smallpox, which, if it had fallen out, _actum est de amicitia_. But it proves otherwise.” Buckingham’s illness, for which he took much physic, produced an imposthume on his head (an effect which followed in the more notorious illness of Wolsey), and he is elsewhere said to be suffering from the _morbus comitialis_. The suggestion of smallpox appears to be the same euphemism which was resorted to in the cases of other exalted personages.

On August 21, 1624, having written of the great mortality from fevers, Chamberlain adds: “Lady Winwood, hearing that her only daughter was fallen sick of the smallpox at Ditton and that they came not out currently,” had gone to her. On December 18, 1624, “the Lady Purbeck is sick of the smallpox, and her husband is so kind that he stirs not from her bed’s feet.” In the first week of June, 1625, the famous composer Orlando Gibbons died at Canterbury, not without suspicion of the plague[907], but according to another opinion of the smallpox[908].

With the year 1629, the causes of death in London began to be published by Parish Clerks’ Hall in a rough classification, smallpox being a regular item from year to year. For the first eight years the deaths from “flox, smallpox, and measles” were as follows:

1629 72 1630 40 1631 58 1632 531 1633 72 1634 1354 1635 293 1636 127

The greatest epidemic, it will be seen, was in 1634[909]. For the years 1637-1646, the figures are lost (owing to Graunt’s omitting them in his Table of 1662, for want of room). But it is known from letters that the autumn of 1641 was a season of severe smallpox as well as plague. Thus on August 26, “both Houses grow very thin by reason of the smallpox and plague that is in the town, 133 dying here this week of the plague, and 118 of the smallpox, 610 in the whole of all diseases.” On September 9, a letter from Charing Cross says: “Died this week of the plague 185, and of the smallpox 101.” The plague mortality continues to be mentioned in subsequent letters, but the references to smallpox cease[910]. On July 16, 1642, one excuses his attendance on some State business because he is sick of the smallpox[911].

About the Restoration the references to smallpox become more numerous[912]. A letter of January 4, 1658 (1659), speaks of “much sickness in the town [London], especially fevers, agues and smallpox.” On February 7, 1660, the earl of Anglesey is dead of the smallpox. In September, 1660, Lord Oxford had a severe attack and recovered; at the same time the duke of Gloucester, on the 8th September, was diagnosed by the doctors to have “a disease between the smallpox and the measles; he is now past danger of death for this bout, as the doctors say.” However he died on 14th September, in the tenth day of the disease, with remarkable evidences (post mortem) of internal haemorrhage, having bled freely at the nose a few hours before his death. The eruption had “come out full and kindly” at the beginning, so that it was not the ordinary haemorrhagic type. On the 20th December, 1660, the princess Henrietta goes to St James’s for fear of the smallpox. On the 16th January, 1660 (? 1661), “the princess is recovered of the measles.” Letters from a lady at Hambleton to her husband in London, May 26, 1661, speaks of smallpox raging in the place, and in the house of her nearest neighbour, her own children having the whooping-cough. In the bills of mortality of those years the deaths in London from smallpox and measles were as follows:

1647 139 1648 401 1649 1190 1650 184 1651 525 1652 1279 1653 139 1654 832 1655 1294 1656 823 1657 835 1658 409 1659 1523 1660 354 1661 1246 1662 768 1663 411 1664 1233 1665 655 1666 38

These figures bring us down to the period of Sydenham, who was the first accurate observer of smallpox in London. With his writings, and with those of Willis and Morton, we begin a new era in the history of epidemics in England. We find, for the first time in the history, an adequate discussion of the epidemiological and clinical facts by the ablest men in the profession. But, as the new era is at one and the same time marked by the cessation of plague and by the enormous increase of various fevers, as well as of smallpox, it falls without the limits of this volume, making, indeed, the appropriate beginning of the new kind of epidemic history which is characteristic of England from the Restoration and the Revolution down to the end of the 18th century. It is clear, from the instances above given, that smallpox was already at the beginning of the 17th century becoming a pest among the upper classes. But to anyone who studies the history over continuous periods it is equally clear that its prominence was then something new and that the horror and alarm which it caused became greater as the 17th century approached its close. And so as not to leave the history of smallpox at this point with a wrong impression of its general virulence, it may be added that Dr Plot, writing of Oxfordshire in 1677, says: “Generally here they are so favorable and kind, that be the nurse but tolerably good, the patient seldom miscarries[913].”

Smallpox in Continental Writings of the 16th century.

It would be beside the purpose of this work to follow the history of smallpox and measles on the continent of Europe. But it will be necessary to say a few words on the contemporary foreign writings upon these diseases, as it is chiefly teaching from a foreign source that we detect in the English authors of the 16th century.

It might be inferred from the classical work of Fracastori[914], published in 1546, that smallpox and measles were frequent and familiar diseases in the author’s experience at Verona. At the same time it is clear that even he, original observer as he was, is in places merely repeating the old statements of the Arabian writers. Thus his statement that everyone has smallpox or measles sooner or later, is the old Arabian tradition or experience, usually joined to the explanation that the cause of that universality was the nourishment of the foetus by the retained and impure menstrual blood, so that all children had to free their constitutions of a congenital impurity sooner or later. So far as Fracastori’s originality comes in, it is clear that he does not regard smallpox and measles as serious troubles. In his second chapter he says:

“First we must treat of those contagious maladies which, although contagious, are not called pestilential, because, for the most part, they are salubrious. Of such are variolae and morbilli. By variolae are understood those which are called also varollae by the common people, from their likeness, I suppose, to the pustules called vari. By morbilli are understood those which the common people style fersae, so-called perhaps from _fervor_. But of these the Greeks do not appear to have treated under any other name than exanthemata. They happen principally in children, rarely in men, most rarely in old people. But they seem to befall all men once in life, or to be apt to befall them unless a premature death removes the individual. In boys the malady is more benign than in adults. For the more part, as already said, they are salubrious, since this ebullition of the blood is something of a purification of the same. It afflicts more or less according to the density of the blood and as the vice is apt or not to be separated from it. If the blood be more pituitous, the pustules are variform, white, round and full of a kind of mucus; but if it be more bilious the pustules break forth more of a dry sort. Where the disease has happened once it is not apt to recur; but there are cases where it has happened more than once.”

In the brief account by Fracastori, all the points are stated for measles and smallpox together; and the opinion is twice put forward that an attack was salubrious as purifying the blood or as freeing it from some vice--an opinion which is still popularly held.

It is not until the latter half of the 16th century that we come to real epidemiological records of smallpox on the Continent,--the works by Donatus on smallpox and measles at Mantua in 1567, and by Betera upon epidemics at Brescia in 1570, 1577 and 1588, in which the more malignant types of smallpox were seen[915]. The treatise most used was that of Alphanus, published at Naples in 1577[916]; it was on plague and pestilential fever, with an appendix on smallpox. Either it or Ambroise Paré’s chapters seem to have furnished the greater part of the English essay by Kellwaye on the plague and smallpox.

In Ambroise Paré’s references to smallpox there occurs one singular line of remark which will serve to bring us back to etymology and to the great pox[917]. The _petite vérole_, he says, has a resemblance to the _grosse vérole_ as sometimes attacking the bones. He had seen that in smallpox cases not only in 1568 but on other occasions: and he gives the details of two cases of smallpox, apparently with periostitis and necrosis, which he compares to cases of the great pox. To express in one word the meaning of such cases, he says, the smallpox and _rougeolle_, not having been well purged, give rise to various troublesome accidents, as the great pox does. One cannot read Paré’s chapters on the _grosse vérole_ and the _petite vérole_ without detecting an inclination to compare them or class them together in nosological characters. The comparison or classification is by no means explicit; but it seems to be in his thoughts, and he would seem, accordingly, to have held until a late period of the 16th century a view of the two diseases which was not unusual at the beginning of that century (as in the treatise of Pinctor and in the accounts of the dreadful mortality of Indians in Hispaniola and Mexico[918]), and was expressed in the popular names given to each disease in France and in England.

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