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Chapter 8 Pathology and Epidemics

As physicians, the Russell brothers were frequently exposed to epidemic diseases.1 Fevers, of great interest to eighteenth-century physicians, were thought to be diseases rather than symptoms of diseases. “The common epidemic diseases at Aleppo are Continual, Intermittent, Remittent fevers, Malignant Remittents,2 and regular and anomalous Erratic fevers to which children are liable,3 Diarrhoea, Dysentery, Pleurisy, Peripneumony,4 Quinsy,5 Rheumatism6 and Ophthalmia,7 common in Aleppo, which all return as regularly as the seasons”,8 as well as the plague – and smallpox that was “sometimes very fatal”.9 Other endemic diseases,10 many that targeted children, included measles, Chincough,11 Putrid Fevers, Petechial,12 and Scarlet Fevers. It is not surprising that the Russells focused on the prognosis, signs, symptoms and treatment of various diseases, including Cutaneous leishmaniasis, smallpox and the plague.

1 Hawgood, “Alexander Russell”, pp. 1–6; Starkey, “Contagion followed”; Aleppo Observed, pp. 164–178. 2 Aleppo2 ii: 300. i.e. typhoid. 3 SP 110/74. In a letter to a patient in Cyprus, Patrick recommended cold baths be taken in the cool of the morning, 11 October 1760. Laidlaw, British in the Levant, p. 145. 4 Respiratory diseases and pneumonia. 5 Peritonsillar abscess. 6 Alexander’s work is cited by Henry William Fuller, On rheumatism, rheumatic gout, and sciatica (London: J. Churchill, 1860), p. 419. 7 Aleppo2 ii: 299, 322. On ophthalmia, see Aleppo2 ii: 299–300. 8 Boott, John Armstrong, vol. 1, p. 114. 9 Volney, Voyage en Syrie, vol. 1, p. 362. 10 Davis, Aleppo, p. 75. 11 Whooping cough. 12 Petechial fever: A malignant fever, accompanied with livid spots on the skin.

Epidemic Diseases: Three Different Research Paths

Rather than providing a comprehensive survey of all medical topics covered in Aleppo, the focus here is on three serious infectious diseases.

1) Embellishing Alexander’s original research on Cutaneous leishmaniasis. 2) Cooperation between brothers as they explored local variolation as pre- judarī), “an acute ج��د ر �ي� .vention for smallpox (Latin: Variola major; Ar contagious disease, with fever and pustules that usually leave permanent scars” (OED). In the eighteenth century, “variolation” was the cutaneous inoculation of material from smallpox pustules, variously named small- ن .pox inoculation, insertion, engrafting or transplantation ,(ṭāʿūn ط�ا �عو� .Development of research13 on the plague (Latin pestis; Ar (3 “a contagious bacterial disease characterized by a fever and delirium, typically with the formation of buboes and sometimes infection of the lungs”; by extension, “any contagious disease that spreads rapidly and kills many people.”14

Oca

Most visitors to Aleppo mentioned the plague and the virulent flesh-eating disease known as the “Aleppo Boil” (Cutaneous leishmaniasis).15 These eruptions, known then as Mal d’Aleppo, Herpes Aleppina, Oca and many other names, are chronic sores that heal slowly and are spread by sand-flies that flourish in waste and sewage. Volney described Mal d’Aleppo as endemic in the region.16 Alexander has been credited with the first clinical account in English of Mal d’Aleppo:

13 Research continues: for example, Marc Galimand, Elisabeth Carniel and Patrice Courvalin, “Resistance of Yersinia pestis to Antimicrobial Agents”, Antimicrobial Agents and Chemotherapy 50:10 (2006), pp. 3233–3236. 14 Starkey, “Contagion followed”. 15 Aleppo1, 262–265, Aleppo2 ii: 307–314. A. P. Gelpi, “Alexander Russell and the Aleppo ulcer”, International Journal of Dermatology 26:2 (1987), pp. 131–134. 16 Volney, Voyage en Syrie, vol. 1, p. 231. Until 1960, the disease was restricted to Aleppo and Damascus. By 2016, Syria’s civil war had triggered an epidemic in the refugee camps and across the region.

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Eruption … is named by the Natives Hebt al Sinne*, or Botch of a year; but by the Europeans and Turks, as if it were peculiar to that place, Il Mal d’Aleppo, the Aleppo Evil, and Haleb Chiban3, the Aleppo Ulcer. It is not however confined to that city; being common almost in the same degree at Aintab, and the villages situated on the banks of the rivers Sejour and Kowick: whence the vulgar opinion of its being produced by the water.17 ن [sic] �ح� ب� �ه�ا �ل��س��ه Heb al Sinne * � ن ح��ل� ب� چ� ب��ا �ي� Haleb Chibani 3 After it is cicatrised, it leaves an ugly scar, which remains through life, and for many months has a livid colour. When they are not irritated, they seldom give much pain … It affects the natives when they are children and generally appears in the face, though they also have some on their extremities … In strangers, it commonly appears some months after their arrival. Very few escape having them, but they seldom affect the same person above more than once.18

These pimples remain for a year and then disappear, leaving a permanent mark. Avicenna and Richard Pococke19 may have mentioned this exotic disease but Patrick provided one of the earliest detailed clinical descriptions – its signs, symptoms and possible treatment, and local distributions – after examining a Turkish patient.20 In 1801, Adam Freer, by then in India, continued to develop his mentor Patrick’s research and published a paper about possible cures of cutaneous disease:21

Dr Adam Freer has communicated an account of the Indian Method of curing the Ring worm viz by a decoction of the fresh bark roots tops or flowers of the cassunda cassia sophera of Linnaeus.22 This remedy is also said to be useful in the herpes miliaris of Sauvages and perhaps, as

17 Aleppo2 ii: 308. 18 Aleppo1, 263. 19 Pococke. Description, vol. 2, pp. 26–28. 20 Aleppo2 ii: 263, 312–314. Gelpi, “Aleppo ulcer”. World Health Organisation, “Control of the leishmaniases”, Technical Report Series 793 (Geneva: WHO, 1990); P. Desjeux. The Leishmaniases Report (Geneva: WHO, 1993), pp. 1–6. Aleppo Observed, p. 155. 21 Adam Freer, “Account of the method employed in Bengal for the cure of the cutaneous disease, commonly known by the name of Ring Worm, the Harpes Serpigo of Sauvages, by means of cassanda vinegar, communicated to Dr Duncan senior”, Annals of Medicine 5 (1800), pp. 371–372; summarized in The Monthly Magazine 37 (1814), p. 321. 22 cassunda (Cassia sophera Lin. Sp. Pl. 542): A purgative, Senna sophera L. Roxb.

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Dr Freer observes, may be advantageously extended to other cachexies and discolourations.23

Local physicians had many different therapies, but knew nothing about “modern discoveries” such as “the use of mercury, ipecacuanha, the Peruvian bark, or the preparations of antimony”.24 Some misdiagnosed the condition and applied different painful caustic remedies including alum, Verdigris, and caustic soda, to remove any encrustations and to extirpate the roots of the tumour.25 Others thought it was caused by a mosquito with a hundred spiky legs, probably a centipede.26 Alexander recounted that “the natives reckon but two spe- cies of this disorder, and distinguish them by the names of male and female; but there is a third kind of Cutaneous distemper, that, though it is commonly ascribed to the bite of a common millipede, or wood louse, seems to me to be altogether of the same nature though milder in degree.” He went on to describe the signs and symptoms of the various types.27 Patrick treated Mal d’Aleppo with mercury. It was not until 1903 that scientists discovered that Oca is caused by an infection by parasitic flagellates of the genus Leishmania and transmitted via spe- cies of sand-flies (Phlebotomus) from animal reservoirs, especially rodents and canines.28 Scientific research came somehow full-circle in 1930, for, curiously is was on the Golden Hamster, a small rodent in Aleppo that was first identified by Patrick Russell, that tests were then made by parasitologist Saul Adler to discover how the disease spread. The Russells suggested the best treatment for Cutaneous leishmaniasis was the external application of a mercurial plaster or Red Precipitate,29 although most patients preferred local remedies. Mercurial plaster (Emplastrum Hydrargyri) was made of olive oil, resin, quicksilver and oxide of lead.30 Red

23 The Critical Review (1801), p. 188. Herpes miliaris: Herpes or Shingles; Cachexia (Cachexies): a wasting syndrome due to a severe chronic illness such as cancer or anorexia. 24 Aleppo2 ii: 132. Antimony: Sb. Ar. ithmīd. 25 Aleppo2 ii: 306–314. 26 Aleppo2 ii: 309. 27 Aleppo1, 262–264. 28 Oumeish Youssef Oumeish, “Cutaneous leishmaniasis”, Clinics in Dermatology 17:3 (1999), pp. 249–254. 29 “Mercuric oxide (HgO), a heavy red crystalline powder obtained by heating mercuric ni- trate, or by heating mercury in the air” (Online Dictionary). 30 John Murray, A system of materia medica and pharmacy (Edinburgh: W. Laing et al., 1810), vol. 2, pp. 412–413. Aleppo1, 262–265; Aleppo2 ii: 311–314.

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Precipitate is Mercuric oxide and is now classified as “very toxic” and banned as a pesticide as “dangerous for the environment” by the European Union.31 In Aleppo Patrick prescribed washing the tumour with milk and water, administering mercury – and waiting – for he claimed that the best treatment was to leave well alone, as such infections usually heal spontaneously. He has since been proved correct, as this is a modern therapy.32

Smallpox

The second example will outline the Russells’ contribution to the eradication of smallpox, partly because their contribution to social and preventative medicine in this way has hitherto been largely unrecognized. Smallpox had a 30% mortality rate in the Ottoman Empire and Europe, where most people contracted the disease before reaching reproductive age. In Aleppo people fled their homes for fear of contagion during a smallpox epidemic.33 There were local precautions too: anyone who contracted smallpox was banned from the bagnio for forty days.34 In 1770 in Aleppo, Patrick advised James Bruce against the dangers of inadequate personal hygiene and pollution, long before bacteria were discovered to be a source of illness:

I set all the servants to work. There were apartments enough. I opened all the doors and windows, fumigating them with incense and myrrh in abundance, washed them with warm water and vinegar, and adhered strictly to the rules which my worthy and skilled friend, Doctor Russel, had given me at Aleppo.35

The Russells were part of a handful of experts on smallpox, many of whom are scarcely remembered. Lady Mary Wortley Montagu discovered the practice of inoculation (then meaning “variolation”) in Constantinople.36 Although the first Britons to be variolated in Constantinople were the sons of Mr Heffernan,

31 Aleppo2 ii: 306. 32 J. Blum et al., “Treatment of cutaneous leishmaniasis among travellers”, Journal of Antimicrobial Chemotherapy 53:2 (2004), pp. 158–166. 33 Marcus, Eve of Modernity, p. 376. 34 Aleppo2 ii: 321. 35 James Macarthur Reid, Traveller extraordinary (New York: W. W. Norton, 1968), p. 115. 36 Aleppo Observed, pp. 159–164.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access 246 Chapter 8 the British Ambassador’s secretary, in 1716, her campaign to introduce variolation to England overshadowed other medical expertise.37 Disfigured her- self by smallpox in 1715, she first observed the variolation of children with the smallpox virus in Adrianople in 1718 and immediately arranged to have her six-year-old son, Edward, “engrafted” at Pera by Charles Maitland (1668–1748), a Scottish surgeon in Constantinople, where he was employed as personal physician to the Wortley Montagu family.38 With Maitland, she then introduced variolation to England.39 In 1721 one of her supporters, Sir Hans Sloane (1660– 1753), President of the Royal Society from 1727,40 was guided by Edward Tarry, a physician who practised medicine in Aleppo and Constantinople, who witnessed a major outbreak of smallpox in 1706, and claimed to have seen 4,000 people variolated in Turkey. Just before he left Aleppo, Tarry was informed by the Greek Patriarch that Bedouin used variolation.41 In Aleppo, the French consul’s four children were successfully inoculated in 1713.42 Whilst aware of Lady Mary Wortley Montagu’s role in promoting variolation in England, Patrick acknowledged pioneering papers presented by Italian and Greek physicians to the Royal Society on variolation. Emmanuel Timoni FRS (1669–1718),43 an Italian who had been educated in Padua and Oxford, claimed that variolation was introduced into Constantinople around 1672 from Circassia and Georgia.44 Yet his four-page summary was largely dismissed as “good for a pleasant little shiver of curiosity at the bizarre and backward

37 Robert Halsband, “New light on Lady Mary Wortley Montagu’s contribution to inoculation”, Journal of the History of Medicine (1953), pp. 390–405. 38 Laidlaw, British in the Levant, p. 121. 39 Montagu (1717). To Mrs. S. C. – [Miss Sarah Chiswell]. Lady Mary Wortley Montagu and Lady Louisa Stuart, The Letters and Works of Lady Mary Wortley Montagu, ed. William Moy Thomas (London: Henry G. Bohn, 1861). 40 Sir Hans Sloane, “An Account of Inoculation” (communicated 1736), Philosophical Transactions 69 (1755–1756), pp. 516–520. 41 Christopher Booth, “The Conquest of Smallpox”, Quarterly Journal of Medicine 57:224 (1985), pp. 811–823 (812); Abbas M. Behbehani, The Smallpox story (Kansas: University of Kansas Medical Center, 1988), p. 11. 42 Abbas M. Behbehani, “The Smallpox story”, Microbiological Reviews 47:4 (1983), p. 460. 43 Emanuele Timoni MD, “An account or history of the procuring the smallpox by incision, or inoculation, as it has for some time been practiced at Constantinople”, Philosophical Transactions 29 (1714–1716), pp. 72–82. 44 W. Woodville, The History of the inoculation of the Small-Pox in Great Britain (London: Phillips, 1796).

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access Pathology and Epidemics 247 practices of the East, but no more.”45 Peter Kennedy, a Scottish ophthalmic surgeon based in London, published his own observations in Constantinople in 1715.46 Then a paper by Jacobus Pylarinus (1659–1718), a Greek physician who trained in Padua and became Venetian Consul at Smyrna, was read to the Royal Society in 1716 but, again, was largely dismissed as an old “wives-tale”.47 A Dutch physician and friend of Fothergill’s and Secretary of the Royal Society from 1765, Matthew Maty MD FRS (1718–1776), published memoirs of a Dutch pastor, M. Chais.48 Cassem Algiada Aga, FRS, who was ambassador for Tripoli in London, and was one of the first three Arab Fellows of the Royal Society, confirmed to Chais that variolation against smallpox was common practice in Tripoli, Tunis and Algiers in the 1740s.49 One of Alexander’s friends, Maty was enthusiastic about variolation, campaigned vigorously; and published his correspondence with Sir James Porter on the topic.50 Thomas Shaw recorded that variolation was known in North Africa;51 Aubrey de la Motraye found it in Circassia, as noted by Voltaire.52 Even in London, Alexander’s colleague, Sir William Watson FRS (1715–1787), undertook clinical trials and compiled medical statistics on the effects of variolation on children.53

45 Timoni, “Procuring the smallpox”. 46 Peter Kennedy, An Essay on External Remedies (London: A. Bell, 1715). 47 Jacobus Pylarinus, Nova et tuta variolas excitandi per transplantationem methodus (Venice: [s.n.], 1715); Emmanuel Timoni, Some Account of what is said of Inoculation or transplanting the Small Pox (Boston: Dr Zabdiel Boylston, 1721). E. Poulakou-Rebelakou and J. Lascaratos, “Emmanuel Timonis, Jacobus Pylarinus and inoculation”, Journal of Medical Biography 11:3 (2003), pp. 181–182. 48 Matthew Maty, “A short account of the Manner of inoculating the Small Pox, on the Coast of Barbary, and at Bengal, in the East Indies, extracted from a Memoir written in Dutch by the Rev. M. Chais, at The Hague”, Philosophical Transactions 58 (1768), pp. 128–131. 49 Royal Society, Arabick Roots. Exhibition catalogue (2011), p. 58. Matthew Maty, “A Paper relating to the Inoculation of the Small-Pox as it is practised in the Kingdoms of Tripoli, Tunis, and Algier”, in J. G. Scheuchzer, An Account of the success of inoculating the smallpox in Great Britain, for the years 1727 and 1728 (London: J. Peele, 1729), pp. 61–63. 50 “Queries sent to a Friend in Constantinople; By Dr Maty, FRS; and Answered by His Excellency James Porter, Esq”, Philosophical Transactions 49 (1755–1756), pp. 96–109. 51 Shaw, Travels, p. 265. 52 Aleppo2 i: 214, 333–334. Voyage de Sr A. de La Motraye, en Europe, Asie et Afrique (London: the author, 1723), cited by Voltaire, “Letter 11: On Inoculation with Smallpox”, Letters on England (1733; London: Penguin, 1980). 53 William Watson, An Account of a series of experiments, instituted with a view of ascertain- ing the most successful method of inoculating the smallpox (London: J. Nourse, 1768).

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Alexander’s only observation about smallpox in Aleppo1 was to note that in 1745 he successfully promoted Sydenham’s methods in Aleppo and, as a result, few died of smallpox.54

Just before my leaving Aleppo, I did hear that it was practised amongst some of the Bedouins there, and went by the name of buying the smallpox; but being then much engaged with other business, it quite escaped my memory, and, indeed my information was so slight, that I did not think it right to mention it in my Natural History of Aleppo.55

“Buying the smallpox”, was found across Europe, Africa and India too.56 It was organized as follows: a cloth was tied around the arm of a newly-infected child. A mother would then haggle over the cost of each pustule or bring gifts, return home and tie the cloth around her own child’s arm. A second method was called “hitting the smallpox”, used in Turkey, by which fluid from a smallpox pustule was collected and rubbed into a cut made into the patient’s skin. Some of Alexander’s medical notes were included in Aleppo2. In October 1742, he noted the tendency for ulceration as the small-pox infection declined: “If the sick survived the eleventh day, few of them escaped corrosive ulcers with carious bones, or hard swellings in the glandular parts.”57 Patrick supported Alexander’s methodology; looked for associated changing weather patterns; and described the treatment of smallpox and variolation.58 Patrick variolated patients in Aleppo: “[t]he child of a Bashaw here, was by my advice inoculated about eight years ago: but that is the only instance I have known among the Turks at Aleppo.”59 Information on smallpox in Aleppo and its varying sever- ity is given for 1743, 1745–1746, and 1750–1751; infection was generally mild in September, progressing to severe in October; growing mild in January and dis- appearing in February.60

54 Aleppo1, 204: Aleppo2 ii: 325. 55 “An account of inoculation in Arabia, in a letter from Dr Patrick Russell, Physician, at Aleppo, to Alexander Russell, MD FRS. Preceded by a letter from Dr Al. Russell, to the Earl of Morton”, Philosophical Transactions 58 (1768), p. 140. James Douglas, 14th Earl of Morton (c. 1703–1768), President of the Royal Society. 56 John Z. Holwell, An Account of the Manner of Inoculating for the Small Pox in the East Indies (London: T. Becket & P. A. de Hondt, 1767). 57 Aleppo2 ii: 316. 58 Aleppo2 ii: 317–318. 59 Patrick Russell, “Inoculation in Arabia”, p. 146. 60 Aleppo2 ii: 318, 321.

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Despite this wealth of evidence, Sir George Baker61 in England argued that medical breakthroughs such as variolation were often accidental “and that some of its most valuable improvements have been received from the hands of Ignorance and Barbarism.” Baker’s irritating statements must have prompt- ed the Russells to write to the Royal Society though they did not name him. They were no doubt spurred on by a fellow Scot, John Zephaniah Holwell FRS (1711–1798), Director of the East India Company, though neither of them mention Holwell’s small pamphlet on smallpox of 1767, in which he criticized Anglophile appropriation of variolation, an ancient tradition found in India and the Levant.62 What the Russells found strange was that, despite all the publicity about the practice in Constantinople obtained in Europe after 1721, the tradition in Syria remained unknown. Therefore, the Russells wrote a joint paper, published as two letters, “An account of inoculation in Arabia”,63 one dated 18 April 1768 by Alexander from his house in London and the other from Patrick sent from Aleppo on 26 November 1767 and cited in Aleppo2.64 Patrick described how variolation was carried out by Bedouin by making a small scratch with a needle that had been rubbed in pus, rather than applied via deeper cuts made by a lan- cet. This paper appeared just after there had been several smallpox epidemics in London (1752, 1757 and 1763). Their aim was to remove any prejudices against variolation that might still exist in Europe, and because they thought that the contents might be a matter of curiosity to members of the Royal Society, they produced compelling evidence. Yet, despite all the evidence, even as late as 1781 many in Europe doubted variolation existed in the Ottoman Empire.65 The then innovative research methods used by the Russells are fascinat- ing. These included surveys of local indigenous knowledge, using informants to corroborate their findings. In his letter of 1768, Alexander explained that he had witnessed the practice of variolation among the Bedouin before he left Aleppo in 1753.66 Alexander thought that variolation was only practised by Christians: something that Patrick at first confirmed.67 Patrick altered his opinion in 1757, when he questioned several Turkish merchants from Baghdad

61 Sir George Baker, An Inquiry into the Merits of Inoculating the Small-Pox (London: J. Dodsley, 1766), p. 1. 62 Holwell, Manner of Inoculating, p. 2. 63 Alexander Russell, “Inoculation in Arabia”, p. 140. Aleppo2 ii: 317. 64 Patrick’s letter of 1768 was reprinted in The Critical Review 28 (1769), pp. 85–90. 65 W. Black, Observations Medical and Political, on the Small-pox (London: Johnson, 1781). 66 Alexander and Patrick Russell, “Inoculation in Arabia”. 67 Aleppo2 ii: 317.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access 250 Chapter 8 and Mosul, who periodically visited Aleppo, and who assured him that variolation was practised in both cities. In Mosul when an epidemic arrived, a public crier would urge the people to have their children inoculated. Patrick discovered variolation in Basra, along the Euphrates and Tigris below Baghdad and in the desert. In 1768, Patrick reinforced Alexander’s initial observations, for he discovered that variolation was practised among Georgians, Armenians, Turkomans, Bedouin,68 Druze, and Kurds in Lebanon,69 Damascus, Mecca and along the coast of Syria and Palestine,70 but recorded that even though smallpox “prevailed to a remarkable degree among the Jews”, they “absolutely reject inoculation”.71 By the end of the nineteenth century, physicians had discovered that micro- organisms transferred diseases, but germ theories were beginning to circulate as early as 1767. Ayurvedic doctors in Bengal explained to Holwell that disease is caused by

multitudes of imperceptible animalculae floating in the atmosphere; that these are the cause of all epidemical diseases, but more particularly of the Small Pox; that they return at particular seasons in greater or lesser numbers; that these bodies, imperceptible as they are to the human or- gans of vision, imprison the most malignant tribes of the fallen angelic Spirits: That these animalculae touch and adhere to everything, in greater or lesser proportions, according to the nature of the surfaces which they encounter; pass and repass in and out of the bodies of all animals in the act of respiration, without injury to themselves, or the bodies they pass through.72

Two years after Aleppo2 was published, on the advice of his lecturer John Hunter, Jenner carried out his famous “innovation” using cowpox pus. Despite knowing Patrick, Jenner showed a complete lack of interest in variolation in India and the Levant in his tract of 1798,73 much to Holwell’s chagrin.74 On the other hand, another friend of Claud and Patrick in Madras, James Anderson,

68 Aleppo2 ii: 317. 69 Defined as Kurds in Aleppo2 ii: 374. 70 Alexander Russell, “Inoculation in Arabia”, p. 140. 71 Aleppo2 ii: 317. 72 Holwell, Manner of Inoculating, pp. 25–26. 73 Edward Jenner, An inquiry into the causes and effects of the variolae vaccinae (London: Sampson Low, 1798). 74 Sudan, Alchemy of Empire, p. 109.

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MD FRSE (1738–1809),75 then one of the most prominent figures of the Madras Medical Service, introduced Jenner’s vaccination to Fort Saint George in 1802 and it was a William Russell76 there who was commissioned to superintend the practice throughout the province of Madras.77 Consul John Barker introduced vaccination into Syria in 1803. In Britain, the Vaccination Act (1840) banned variolation. Smallpox was effectively eradicated by 1979.

Of the Plague and Contagion

Plague epidemics seriously endangered travellers and residents in the Levant.78 Both brothers were experts on the plague.79 There were eight plague pandem- ics over fifteen years during the eighteenth century that killed 15% to 20% of the population of Aleppo: over 80,000 people died there from the plague in 1760 alone. The Russells witnessed many plague epidemics first hand, provided information on its morbid anatomy and prescribed treatments for those infected. It is not surprising to discover that, in Patrick’s library of over 900 items that were listed in the Squibb’s Catalogue, approximately 35% were medical authorities on the plague. The earliest in Patrick’s collection was published in 1527 by Giovanni Battista, an Augustinian friar and head of Naples Public Health Board.80 The most recent was by Paolo Assalini (1759–1840), Duke of Modena, who accompanied Napoléon Bonaparte’s Syrian expedition in 1799 as far as Jaffa.81 Alexander included a whole chapter (V) on the plague in Aleppo1 and discussed its appearance, symptoms, relapses, treatments and different opinions

75 Pratik Chakrabarti, “ ‘Neither of meate nor drinke, but what the Doctor alloweth’ ”, Bulletin of the History of Medicine 80 (2006), pp. 1–38. Anderson obtained his MD from Edinburgh in 1800. 76 Possibly Patrick’s great-nephew, Sir William Russell MD FRS, LRCP, First Baronet of Charlton Park (1773–1839), a Company surgeon in Calcutta; created baronet in 1832 for his medical service in the London cholera epidemic. Cholera, long endemic in India, spread along trade routes to Russia and beyond in 1817 so did not figure in Aleppo. 77 John Baron, The Life of Edward Jenner (London: H. Colburn, 1827), pp. 424–425. 78 Aleppo2 (Book IV). 79 Starkey, “Contagion followed”. 80 Giovanni Battista da Napoli, Opera et trattato che insegna molti dignissimi secreti contra peste con li quali subito se guarise (Venice: Bernardinum de Vitalibus Venetum, 1527). 81 Paolo Assalini, Observations on the disease called the plague, the dysentery, the ophthalmy of Egypt, and on the means of prevention, transl. Adam Neale (London: J. Mawman, 1804).

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access 252 Chapter 8 on the “method of cure”, where it came from and its progress. As Carsten Niebuhr had noted,

whatever has been said concerning certain diseases preserving those who are affected by them from the contagion of the plague, is founded on prejudices which have been refuted by experience, and particularly by the observations of Dr [Alexander] Russel, a skilful physician at Aleppo.82

Alexander’s “Rules to be observed by those who are among the infected” were as follows: (1) Don’t go without breakfast; (2) avoid excesses and violent passions [of the mind] and immoderate evacuations “but not to live more abstemiously, either with regard to eating or drinking, than usual: perhaps one or two glasses of good wine more than customary, might rather be beneficial than otherwise; and a plentiful use of acid liquors, such as a very weak sour punch in the summer, is not only agreeable but useful”; (3) when in a sick room, don’t swallow your saliva and breathe naturally but through a handkerchief or sponge soaked in vinegar or infused with rue; (4) hold your breath when taking a patient’s pulse, then leave the sick room and wash your mouth, face and hands with vinegar; (5) change your clothes as soon as you get home (after visiting the infected or passing through the Bazaar) and wash yourself in vinegar, as before; air or smoke infected clothes with sulphur; (6) as a medical precaution, a large dose of extract of (Peruvian) bark with a draught of wine and water mixed with elixir of vitriol [sulphuric acid], twice a day.83 Patrick reiterated these precautions, adding “A glass of generous wine, or any other cordial more agreeable to the choice, may be taken before dinner, in case of languor, or oppression at the stomach, from fatigue, fetor or apprehension. I found a rummer of old hock very grateful, on such occasions, in the hot weather.”84 Despite faith in Divine Providence, most people tried to escape an infected city, and the bazaar and khāns became deserted during an epidemic.85 Patrick described how Turks and Christians used many precautions for their own preservation. The qāḍī ordered a beneficial verse of the Qurʾān be recited from minarets at stated times of prayer by an imām and urged all Muslims to strictly observe their religious devotions.86 Dread of contagion in the lower classes

82 Niebuhr, Voyage en Arabie, vol. 2, p. 280. 83 Aleppo1, 260–261; Aleppo2 ii: 385–387. Treatise of the Plague, p. 161. 84 Treatise of the Plague, pp. 577–758. Rummer: a large drinking-glass indented with prunts to ensure a safe grip. 85 Aleppo1, 252; Aleppo2 ii: 376. 86 Treatise of the Plague, pp. 35, 49.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access Pathology and Epidemics 253 meant it was difficult to find persons to nurse the sick. Priests, grave-diggers and those who washed the dead succumbed, and sometimes whole sectors, such as the Armenian bakers, were smitten, causing subsequent logistical problems. In 1762, the qāḍī published orders to reduce the number of shaykhs attending funerals and forbade women shrieking in the funeral processions to reduce public alarm and not to disturb the sick. The shaykhs obeyed: the women did not. Alexander provided “Methods used by the Europeans for their preservation from it”, “Manner of shutting up” and “Precautions after it”.87 Europeans who stayed were shut up in their houses during the major outbreaks between 1740 and 1753.88 In 1761 many higher ranking Aleppines stayed at home, and did not allow their women to walk abroad or receive visitors indiscriminately at the harem. Patrick observed strict precautions during an epidemic and laid up provisions before shutting up. He drafted a chapter in Aleppo as early as 1752, entitled “Of the method of shutting up, practised by the Europeans in Syria, for their preservation in times of pestilence.”89 Yet he “was sufficiently convinced that a physician must unavoidably be exposed to no small degree of danger in the beginning and in the decline of a plague.”90

When the first symptoms of that scourge of human nature at any time appeared, far from shutting himself up, as was customary with Europeans, Dr Russell remained calm and collected, and displayed a steady perse- verance in the discharge of his duty,… At the most imminent risk did Dr Russell then apply himself to the treatment of the diseased.91

In 1762, Patrick moved from his own home to that of a gentleman on the west side of Khān al-Jumruk. In one afternoon alone, he was besieged by three or four hundred sick or recovering patients seeking advice, some coming from villages and surrounding suburbs. Swelling the numbers were his assistants arriving for medicines from him, that he let down in a copper bucket on an iron chain from his window.92

87 Aleppo1, 192–193, 197–202, 225–229, 234–235, 240–242, 250–261. 88 Aleppo (1757), p. 228; Aleppo2 ii: 373. Davis, Aleppo, p. 75. 89 Aleppo2 ii: 373–388. 90 Treatise of the Plague, p. 22. 91 Cunningham, Lives, vol. 3, pp. 118–119. 92 Treatise of the Plague, pp. 65–68.

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The Impact of The Treatise of the Plague on Aleppo2 A critic in The Monthly Review commented that the chapter on the plague in Aleppo2 “appears to contain nothing which has not been introduced in the editor’s late elaborate work [Treatise of the Plague] on that disease”.93 The Treatise of the Plague, “a very valuable addition to our medical and political information”.94 was either a preparatory study for Aleppo2 on the same subject or, more likely, the text on the plague in Aleppo2 is little more than a précis of the 784–page Treatise of the Plague itself.95 It cost £1 7s in 1791 (equivalent to c.£189 in 2016), in 1796 for £1.10s second-hand, and fetched £5,000 at Sotheby’s in 1999 (the equivalent of c.£7952 in 2016). It was translated into German as Abhandlung über die Pest and published in Leipzig in 1792–1793. It was summarized at length, with many excerpts in The Analytical Review.96 It was composed as a series of “books” in which Patrick outlined measures that could be taken to protect people from the plague, including quarantine, es- tablishing lazarettos at ports, and the administration of the police in times of pestilence. Considered “the finest volume on the plague”97 that afforded “the latest experience the best and most rational assistance”,98 the first “book” contained a historical account of the plague in Aleppo and its fluctuating nature, epidemiological observations, and discussions about possible causes. Based on his own case notes, Patrick arranged the signs and symptoms into six different classes.99 Building on material he had prepared for Aleppo2, Patrick published further statistics with a breakdown of mortality estimates in his Treatise of the Plague; 7,767 burials in 1761 and 11,883 in 1762, were recorded by observers at ceme- teries, that is, around 15%–20% level of mortality in the city.100 From August 1762 to around June 1769, Patrick’s colleague, Reverend Thomas Dawes, kept a moving account of events, violent epidemics and weather there as part of his

93 Monthly Review 18 (1795), p. 257. 94 Treatise of the Plague. Monthly Review (1794), p. 67. 95 Aleppo2 ii: 338–339, 347, 354, 357–360, 377, 384. A copy, listed in Squibb, Catalogue, p. 46, no. 728, contained manuscript notes. 96 Analytical Review 10 (1791), pp. 259–270. 97 Arnold Zuckerman, “Plague and contagionism in eighteenth-century England”, Bulletin of the History of Medicine 78/2 (2004), p. 303. Carl Ignaz Lorinser, Die Pest des Orients (Berlin: Enslin, 1837), pp. 105–110, 142–144, 177, 252, 280, 341–342. 98 Critical Review 2 (May 1791), pp. 1–9. 99 Boott, Memoir of John Armstrong, vol. 2, pp. 69, 91, 109, 112–165. 100 Aleppo2 ii: 344–345. Treatise of the Plague, p. 33. These statistics are discussed by Panzac, La Peste dans l’Empire ottoman, 1700–1850 (Leiden: Peeters, 1985), pp. 353–357.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access Pathology and Epidemics 255 epic account of the plague in Aleppo.101 He recorded that 200 to 300 persons were buried each day during the dreadful pandemic that raged between 1761 and 1762. Morbidity numbers were difficult to calculate as the Muslims kept no death register but Dawes thought that there were as many as 300 burials a day in June at one or other of the seventy-two burial grounds within seven miles (11 km) of the city. Jewish and Christian communities had only one burial ground each and kept registers that indicate a loss of 3,500 lives in five months. In his Treatise of the Plague, Patrick noted that he encountered 4,400 cases of the plague himself. The plague was especially dangerous during intensely hot summers but the plague occasionally continued into the winter, even after a frost or falls of snow. This was exceptional, for cold weather usually killed off summer epidemics. Generally, incidences of the plague began to decline in July and had ceased by August, September or October.102 Just in one month, May 1761, Patrick recorded 171 deaths, with the figure rising to 670 by the beginning of June, when he used to treat 300–400 people in an afternoon and under such circumstances was “held in high esteem by all those who came under his care”.103 In complete contrast to Aleppo2, much of the commentary in Patrick’s Treatise of the Plague is in the first person, conveying a keen sense of the dangers of plague epidemics reflecting many personal experiences. In this Treatise of the Plague, Patrick described, month by month, the course of the plague at Aleppo in the years 1760 to 1762, noting that “I should look back with satis- faction on the dangers incurred in collecting a part of my materials.”104 Fears were real and although I have found no evidence that either brother caught the plague, Patrick described, after many gruelling days taking serious risks when administering to the sick, how easy it was to imagine he had contracted the disease:

The pains felt in the groin, by those communicating with the infected, and which are followed by no swelling, are I believe very often merely imaginary. I have myself, especially when alone in the evening without society, and fatigued by business, writing, and thinking on the same subject, been sensible of shooting pains in the groin; insomuch, that I have

101 Thomas Dawes, “An account of the plague at Aleppo in a letter to the Rev Charles Lyttelton LLD, Dean of Exeter”, Philosophical Transactions 53 (1762), pp. 39–47. 102 Treatise of the Plague, pp. 44, 94. 103 R. L. Jayakody, “Russell of Russell’s Viper fame”, The Ceylon Medical Journal 46:2 (2001), pp. 39–40. 104 Treatise of the Plague, Preface. Marcus, Eve of Modernity, p. 51; Mariti, Travels through Cyprus, Syria, and Palestine, pp. 194–206, on the 1760 pandemic.

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several times gone to bed in the firm persuasion of having caught the infection, and on awaking the next morning, have hardly had resolution to touch the part, from the dread of finding my suspicions confirmed. But impressions of this kind vanished when the spirits were recruited, and the attention engaged in the business of the day.105

Different Types of the Plague The second “book” was a medical account of the disease based on his experiences and methods of treatment as well as observations by other physicians in the area in 1720 and 1721. Patrick identified twenty-eight cases of re-infection and relapses of the disease. It was only in 1894 that Kitasato Shibasaburō (1853–1931) identified Bacillus pestis (now known as Yersinia pestis) which causes the specific infectious fever known as the plague.106 In other epidemics of the plague the most important arthropod vector was the Indian rat flea, Xenopsylla cheopis, transmitted from rats (Rattus rattus) to humans. In 1761, Patrick almost identified the connection between fleas and contracting the plague when he described red spots like flea bites on a patient.107 He “met with many instances of the disease being communicated by coverlids, carpets and apparel purchased from infected houses.”108 These may well have harboured vector fleas, a carrier that Patrick never specifically identified. Nowadays, several types of plague are recognized. First, Pneumonic Plague is an infection of the lungs; secondly, Bubonic Plague is an infection of the lymph nodes; thirdly, Septicaemic Plague is due to an infection in the blood stream. Secondary pneumonic plague is caused when Septicaemic Plague is transferred from the bloodstream into lung tissue. It is now recognized that one virulent form of the plague, primary Pneumonic Plague, that has a high fatality rate, is transmitted by inhalation of fine infective droplets expelled from an infected person by coughing or sneezing, and can be transmitted from person to person without the involvement of insect vectors including human fleas, Pulex irritans, and does not involve rats as intermediate hosts.109 Left untreated, the plague kills about 90% of those infected and often within a week.

105 Treatise of the Plague, vol. 1, p. 174. 106 https://en.wikisource.org/wiki/1911_Encyclop%C3%A6dia_Britannica/Plague. 107 Treatise of the Plague, vol. 1, p. 133, 134; Case xv. 108 Treatise of the Plague, vol. 1, p. 287. 109 Lars Walløe, “Medieval and modern Bubonic Plague”, Medical History Supplement 27 (2008), pp. 59–73.

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Patrick clearly identified various plague types, distinguishing re-infection (what is now identified as septicaemic or pneumonic plague) from relapse.110 The Treatise of the Plague, itself a sophisticated tome, has an extensive appendix which contains thorough daily records of one hundred and twenty case histories Patrick observed, and in many instances his patients survived. Although the enterobacterium Yersinia pestis was not identified as the cause until 1894, some of Patrick’s cases were quoted as late as 1936111 for they were described precisely, exactly as they appeared to Patrick. They may well be the earliest set of medical case studies of the plague from the Middle East.112 These remarkable case studies provide exceptional information about all sectors of Halebi society and precise medical descriptions of the horrific symptoms and methods of containment, as is seen in two Armenian examples:

CASE XIX. June 1761. A boy, the brother of the woman’s husband (Case XVIII: an Armenian woman in her seventh month of her first pregnancy who also died) was seized on the nineteenth, a bubo appearing immediately in the right groin. He was bled, and took the alexipharmic mixture.113 He had not vomited, and had no nausea. – On the 2d, diarrhoea coming on, diascordium was added to the mixture, but without effect; for the looseness continued, and he became very hot and restless, particularly in the night. – The morning of the 3d, instead of any remission, he lay in a state, almost, of insensibility. The diarrh[o]ea, being in no degree restrained by the diascordium, continued. The bubo remained as before. When asked, at intervals, if he felt pain, he said he did not; nor did he make any complaint, though he appeared to be very restless. He died in the night. The only person in the house, where this boy and the pregnant woman died, who escaped the infection, was an old man, the father of the boy. His wife, and an elder son, had perished before. The wife was taken the eleventh of June, and died the night of the twelfth. The son was taken the twelfth, had an incessant vomiting, and a carbuncle on the hip, which gangrened rapidly, and had spread to a considerable breadth, in the space of three days. He died on the 3d day in the afternoon.

110 Treatise of the Plague, Preface, Book II. 111 Liande Wu, Yung-han Chen, R. Pollitzer and Chang-yao Wu, Plague (Shanghai Station: Weishengshu National Quarantine Service, 1936), p. 370. 112 Van den Boogert, personal communication. 113 Substances used to protect the heart against poison.

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CASE CXVII. October 1761. An Armenian girl, between seven and eight years old, was seized with the plague, on the third of June, 1761. A bubo appeared in the right axilla on the second day, and a carbuncle was soon after protruded on the right side. She had a vomiting the two first days; and the febrile symptoms continued to run high till the end of the first week. The bubo, advancing favourably to maturation, opened the 20th day. The carbuncle spread to nearly twice the size of a crown piece, and, after the separation of the black crust in the second week, continued to discharge copiously for more than a fortnight. The discharge from the bubo was also considerable, and the ulcer was not completely healed till about the end of August. From that period, the girl, who had been greatly weakened, and emaciated, began to recover apace, and, though still pale and feeble, she was in other respects very well by the middle of September. On the fourteenth of October, she was a second time attacked with the plague. A bubo appeared in the left thigh, accompanied with the most alarming symptoms, and she expired on the 4th or 5th day of the disease. In this case the discharge from the eruptions, in the first attack, had been very considerable.

The second example was probably a case of septicaemic plague. If septicaemic plague is left untreated, it progresses to pneumonic plague. Patrick probably even identified cases of secondary highly infectious pneumonic plague that is caught by breathing in droplets or as a progression from another type of the plague.114

Possible Causes of the Plague In the mid-eighteenth century, physicians were still speculating on the treatment, distribution and causes of the plague but the Russells were among the principle advocates of the notion of contagion.115 The third “book” was on pestilential contagion and its abstruse nature, thereby challenging the tradi- tional Galenic view that diseases were disorders caused by internal imbalance of the humours. Patrick based his assertion of its contagious nature on a meticulous study of records of an epidemic of the plague in Marseilles in 1720. He recalled that Avicenna thought that there were “traces” of diseases left in the air by a sick person, but he was unsure whether either Avicenna or Rhazes

114 Emilie Savage-Smith, personal communication. 115 Starkey, “Contagion followed”.

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(Muḥammad ibn Zakariyyā al-Rāzī, c. 854–925) expressly recognized disease as contagious.116 Other possible causes ranged from divine intervention,117 famine, war, miasma, realignments of the planets and/or earthquakes. Dormant infection of the plague was exacerbated by fear: “Terror, despondence, and other debilitat- ing affections of the mind, have been universally held of a most dangerous tendency, in times of pestilence” whilst those of more cheerful disposition had a lively hope of escaping infection.118

I have known several persons who had, till then, without the least sus- picion, frequented the sick, struck suddenly with a panic, and imagine themselves ill. They felt shooting pains in their groins, confusion in the head, and a loathing. Though in some these complaints were purely imaginary, and soon vanished, in others they proved real; the symptoms increasing, and being followed by eruptions. In such cases, I suspected the latent infection to have been excited by terror.119

Only after increased scientific understanding and meteorological expertise could natural explanations replace supernatural interpretations during the Enlightenment.120 Yet, as Christian Gottlob Heyne, a respected classicist of the North German Enlightenment, and Georg Forster’s father-in-law, wrote in 1788, “Enlightenment, progress in science, chemistry, and medicine, along with historical narratives are the only weapons by which magical nonsense can be bat- tled effectively. Thus, it is remarkable that in an era where such Enlightenment is more widely spread than ever, this dangerous plant has not only spread its roots, but has also sprouted new branches.”121 In a world where sudden and unexpected death was a real possibility, it is not surprising that epidemic disease and earthquakes were linked in people’s imagination: both strike unpredictably and erratically. Such possible connec- tions led Alexander to study earthquakes and weather patterns in 1743, 1744 and 1753.122 There were earthquakes in Aleppo in 1759 and 1760 and a coincident

116 Treatise of the Plague, p. 331. 117 Treatise of the Plague, pp 35, 49. 118 Treatise of the Plague, pp. 575–576. 119 Treatise of the Plague, p. 303; cf. Aleppo2 ii: 349. 120 Allan, Scotland in the eighteenth century, p. 78. 121 Quoted by Monika Neugebauer-Wölk, Aufklärung und Esoterik, p. 317. 122 Aleppo1, 159, 161–162.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access 260 Chapter 8 resurgence of the plague in March 1761, followed by another earthquake in April with at least ten aftershocks.123 In a paper for the Royal Society, Patrick recorded that it had been unusually dry in the spring of 1759, the summer tem- perate and though rains came at the end of September, autumn was drier than previous years; a slight seismic shock was felt in Aleppo on 10 June 1759, followed by more severe shocks in October and November that year. The temper- ature was 50oF and the barometer stood at 28–9. Further earthquakes occurred in Aleppo in December 1759 and January 1760.124 Correspondingly, there was a series of epidemics of the plague in 1760, 1761 and 1762. Yet in neither Aleppo2 nor his paper for the Royal Society did Patrick link earthquakes and incidences of the plague.125 Instead, Patrick focused on the impact of earthquakes that “spread universal terror” among the population and on the state of the weather when they occurred. They did not then know that earthquakes were caused by rupture of geological faults, landslides or volcanic activity. Others thought that unseasonably warm weather influenced by the planets might corrupt the air but Patrick rejected a Syrian fallacy about the moon’s planetary influence on the plague.126 Modern epidemiologists are re-examining the possibility that climatic changes in Kazakhstan could lead to increased outbreaks of bubonic plague.127 Like many of his colleagues, Patrick thought diseases were caused by nox- ious miasma from decaying organic matter and poor ventilation, arguing that the plague developed from an unhealthy state of the air or that a corrupt state of the air attends all epidemics.128 In Case XIV he described the unhealthy environment he readily identified with contagion: “This was one of those misera- ble dwellings which, from the want of ventilation, the sordid beds, and neglect of cleanliness, I always considered as dangerous receptacles of contagion.”

123 “An account of the late earthquakes in Syria: in a letter from Dr Patrick Russell, to his brother, Alexander Russell, MD, FRS”, Philosophical Transactions 51 (1759–1760), pp. 529–534. 124 Patrick Russell, “Earthquakes in Syria”; summarized in George Sale (ed.), The modern part of an universal history 43 (London: T. Osborne, 1760), pp. 62–63; and John Kitto, Palestine (London: C. Knight, 1841), vol. 2, pp. lxxxix–xc. 125 Aleppo2 i: Appendix xix, earthquakes in 1753, vol. 2, pp. 288–290 (1742, 1743 and 1744); p. 295 (1749); p. 297 (1750). 126 Aleppo2 ii: 339. 127 Nils Chr. Stenseth et al., “Plague dynamics are driven by climate variation”, Proceedings of the National Academy of Sciences 103:35 (2006), pp. 13110–13115. 128 Treatise of the Plague, vol. 1, p. 296.

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Anti-contagionists tended to endorse miasma theories. Some of their arguments were published anonymously by the “Explainer” in 1722129 and promoted by the man-midwife Sir Richard Manningham (1690–1759) in 1758,130 but were firmly rejected as absurd in Patrick’s Treatise of the Plague.131 By the late eighteenth century, one might have expected that the concept of contagion was generally accepted. Yet, from 1815 onwards, Charles Maclean (fl. 1788–1824) argued repeatedly, with vicious prolonged attacks on the then deceased Patrick, that pestilential contagion did not exist;132 and that it was a “papal conspiracy” by Pope Paul III (1468–1549) and his physician, Fracastorius, to stop proceedings at the Council of Trent (1545).133 Maclean even claimed that it was an Arabian Nights fantasy, and quarantine was not necessary134 – but it is Patrick’s contagionist ideas that dominate medical thinking today.

Quarantine and lazarettos Patrick’s fourth “book” focused on quarantine and the dangers of the disease being transmitted by merchandise, citing a case study of an epidemic in Messina in 1743. Merchants took stringent precautions in Turkey against contracting the plague.135 When Patrick served on the “Delawar” in the late 1740s he would have experienced safety measures and quarantine procedures first hand because sea captains were issued with Quarantine Warrants for the “re- lease or discharge from quarantine or referring to the Customs Commissioners petitions relating to quarantine issued” before they could deliver their cargoes.136 Patrick focused on Bills of Health, most of which he deemed un- reliable and provided examples of Bills of Health issued in Cyprus to William Cleland, Captain of the “Delawar”, for its voyage to London in 1735.137 He criticized Sir James Porter’s naive reliance on safety measures taken by the Levant Company for shipping goods to England, commenting further that

129 Explainer, Distinct notions of the plague, with the rise and fall of pestilential contagion (London: J. Peele 1722). 130 Richard Manningham, A Discourse Concerning the Plague and Pestilential Fevers (London: J. Robinson; 1758). 131 Treatise of the Plague, p. 329. 132 Mark Harrison, “Maclean, Charles (fl.1788–1824)”. ODNB (2004). 133 Treatise of the Plague, p. 329. 134 Mullett, “Politics, Economics and Medicine”, p. 231. 135 Treatise of the Plague, p. 392. 136 William A Shaw (ed.), “Quarantine Warrants: 1745”, Calendar of Treasury Books and Papers (London, 1903), vol. 5, pp. 789–792, lists warrants issued to the “Delawar” (on which Patrick served a year later) and to the “Thames” on which William Russell served. 137 Treatise of the Plague, p. 366.

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he must entertain an ill opinion of mankind who can believe any merchant, in the Levant, from lucrative motives, would risk the health of his country, by exporting merchandise when the plague was raging in the place; or under the conviction of his own mind, that his commerce, highly advantageous as it might be to himself, might in the event involve thousands of his fellow creatures in misery.138

Patrick then explained that no British ship, bound for England, was permitted to depart from Turkey with a “foul patent”.139 Nevertheless, he proposed im- proving regulations, especially in Turkey, but considered that it would be more satisfactory to provide more rigorous regulation when goods arrived in Britain. To expand his study of the plague, Alexander had returned to Britain via quarantine stations in 1754 to enquire into the regulations and management of lazarettos in France and Italy. In 1772, Patrick also visited lazarettos on his return journey as part of his study of the economic and social implications of an epidemic and the commercial losses to international trade caused by long periods in quarantine.140 In the fifth “book” Patrick described lazarettos and methods of ensuring quarantine, providing counter-arguments to those who objected to such arrangements and urging those familiar with architectural de- sign or policing ships to provide substantive plans. He discussed the dangers of infected merchandise and precautions to be taken, including fumigation and even the burning of an infected ship and its merchandise.141 In his Treatise of the Plague, Patrick reviewed extant Quarantine Laws and decisions made by relevant Privy Council committees. Due to the 1753 Quarantine Act, British ships were obliged to face a lengthy quarantine in Mediterranean ports if incidences of the plague were suspected. This meant that the mercantile community loudly complained about extravagant regulations. Patrick continued: “at present, quarantines, without being so secure a defence as is commonly imagined, are a certainly heavy tax upon commerce. The benefit they promise to the State is very precarious, the detriment to the

138 Treatise of the Plague, p. 368. Birsen Bulmuş, Plague, Quarantines and Geopolitics in the Ottoman Empire (Edinburgh: Edinburgh University Press, 2012), pp. 54, 58: wrongly at- tributes this to “John Russell, himself a factor of the Levant Company” and incorrectly describes Alexander as a “British trader” with the wrong date of 1744 for Aleppo2. 139 Treatise of the Plague, Preface, p. 351. 140 Treatise of the Plague, p. 34, Aleppo2 ii: 383. Marcus, Eve of Modernity, p. 376, cited SP 110/47 f. 18 (31 December 1761) on the effects of the plague on commerce. 141 Treatise of the Plague, pp. 424–425.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access Pathology and Epidemics 263 merchant is real.”142 As a better alternative with distinct commercial advan- tages, Patrick supported recommendations by the English prison reformer, John Howard (1726–1790), to allow ships from the Levant to be quarantined in British ports143 and that a lazaretto be established near the Port of London – as Alexander had suggested to William Pitt the Elder (1708–1778, later 1st Earl of Chatham) as early as 28 March 1758, along with recommendations for “a well- regulated Board of Health”.144 A lazaretto was eventually approved by Act of Parliament for a site at Chetney Hill, near Chatham on the River Medway, on 28 July 1800 to replace the floating lazarettos that were established from 1755.145 In the sixth “book” of the Treatise of the Plague, Patrick reviewed policing arrangements and regulations available during plague epidemics. He referred to Mead’s somewhat harsh opinion of otherwise sensible regulations of 1603 in London and to associated parliamentary proceedings of 1720 and 1721. In 1720, Mead had published an influential tract146 that did much to improve the understanding of transmittable diseases. A staunch contagionist, Mead had suggested that the plague was carried westwards by large caravans across the Arabian and Syrian Deserts, from Baghdad and Basra to Aleppo and on to the Mediterranean. He called for strict quarantine measures that led to a new Quarantine Act in 1753. Agreeing with Mead in his Treatise, Patrick urged regulations be created that immediately separated the sick from the healthy, provided provisions for those shut up in their houses, and prevented dispersal of sick people from centres of infection. He considered the policing of plague environments and examined the practice of fumigation of infected houses. He urged governments not to deceive the public with false representations about the actual, with all the dangers of anarchy that might follow. Quarantine and the policing and monitoring of infectious diseases continue to be a powerful core part of any public health response to controlling epidemics of communi- cable diseases – just as the Russells had advocated in the eighteenth century.

142 Treatise of the Plague, pp. 466–467. 143 John Howard, An Account of the principal Lazarettos of Europe (Warrington: William Eyles, 1789), pp. 25–27. 144 Alexander’s “corrected scrawl of part of a memoir” drawn up apparently at the Minister of State’s request is included in Treatise of the Plague, pp. 438–440. 145 P. Froggatt, “The Lazaret on Chetney Hill”, Medical History 8 (1964), pp. 44–62. 146 Richard Mead, A short discourse concerning pestilential contagion and the methods to be used to prevent it (London: Samuel Buckley, 1720). Patrick owned several copies of this tract.

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Advising the Privy Council of Great Britain Due to their expertise on the plague, Alexander and Patrick both served on Privy Council committees. The plague has not occurred in Britain since the late seventeenth century and the need for quarantine was established by the Quarantine Act 1710; the Levant Trade Act of 1721 was passed following an outbreak in Marseille that Patrick later analysed in his Treatise of the Plague. Further acts were passed in 1733, 1743 and 1753. It was only after the Levant Company lost its monopoly over trade with Turkey that the Act for Enlarging and regulating Trade into the Levant Sea (1753) and an Act to Oblige Ships to Perform Quarantine (1753) were passed. According to these Acts, all ships load- ing in the Levant, their cargoes and passengers had to undergo quarantine. They had to stay in lazarettos in Malta, Venice, Messina, Livorno, Genoa or Marseille. Alarmed by news of the plague in Portugal and because of his study of the plague in Aleppo1, Alexander was engaged by Pitt the Elder in October 1757 to advise the Privy Council on quarantine regulations. Alexander even visited Lisbon in a sloop of war after rumours of the plague there following an earthquake on 1 November 1755. This meant Alexander could apprise the British government of the situation, which he presented in a letter to Pitt the Elder on 28 March 1758.147 According to Patrick, this visit to Lisbon revived the concept of lazarettos: for Alexander drew up plans for a lazaretto and methods for checking the progress of any contagion.148 In his opinion, Alexander reckoned that the existing quarantine practice provided “no security against infection”:

in consequence, he said, mainly of the ignorance of those in whose hands its execution was left, they being custom house officers utterly unacquainted with the laws affecting the development and spread of pestilential diseases, and, also, of the want of any fixed or uniform mode of procedure in the different ports of the kingdom. There was no Board of Health, or medical superintendent of quarantine, to advise the Government on such matters. Altogether, the practice was of the rudest and most mechanical nature; and upon any sudden alarm of danger to the public health from abroad, all was irregularity and confusion.149

147 Treatise of the Plague, pp. 437–440. 148 Treatise of the Plague, pp. 438. 149 Parliamentary Papers (London: HMSO, 1861), p. 42. Charles Maclean, Evils of quarantine laws and non-existence of pestilential contagion (London: Thomas and George Underwood, 1824), pp. 43–44, 276–277.

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The public continued to be nervous. In July 1760, Alexander and other senior staff even had to countermand a false rumour that the plague had broken out at Saint Thomas’s Hospital by publishing a letter in the London Gazette. Legislation followed in 1770. The 1780 Act enforced a quarantine period of forty days and the 1788 Quarantine Act further strictly restricted cargoes. In 1799 an Act to Encourage Trade into the Levant Sea was passed. Another epidemic of the plague broke out in the Levant in 1799 so the Privy Council re- solved to draw up measures to prevent the infection arriving in Britain. They appointed a Committee to draw up quarantine regulations and to draw up permanent precautionary measures to be adopted in the future. The celebrity of Patrick’s Treatise of the Plague naturally meant he was asked to assist. This he cheerfully granted. The most influential members of the 1799 Privy Council Quarantine Committee were Patrick Russell and Sir Gilbert Blane,150 who was full of praise for the “fulness [sic] and accuracy” of Patrick’s Treatise of the Plague: “For far- ther information, I beg to refer you to the work of Dr Russell who has deserved highly of the world for the intrepidity ingenuity and industry he has displayed in his labours on this branch of his profession.”151 Other members of the Committee included Dr James Johnson, representa- tives of H. M. Customs, and members of the Levant Company’s Quarantine Committee. Patrick repeatedly complained that the Regulations the Com mittee drew up did not go far enough and signed a statement along with another member, Sir Lucas Pepys, to that effect, that accompanied the final report of March 1800. To Claud Russell’s evident distress:152 “By some strange oversight, the important and solicited services which Dr Russell at this time gratuitously rendered to his country were never acknowledged even by a letter of thanks, although the Doctor was the only member of the Committee who did not hold some official situation under Government.”153 Nevertheless, a more responsible policy was established following the 1799 Privy Council Quarantine Committee and a new Quarantine Act followed in 1800 that put an end to the absurdity and expense of quarantine stations in the Mediterranean so the required quarantine period could be undertaken off British shores, usually at Stangate Creek.154

150 A Scot, Sir Gilbert Blane, physician to Saint Thomas’s Hospital 1783–1795; then Government consultant with especial interest in the British Navy. 151 Sir Gilbert Blane, Observations on the diseases of seamen (London: Murray and Highley, 1799), pp. 611, 620. 152 Arcadian Library, “Memoranda”. 153 [Home], “Patrick Russell”. 154 The site at Chetney Hill was marshy so they used floating lazarets.

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Another Act followed on 12 March 1805 that specified the duration of quarantines to be performed.

Medical Arithmetic and Its Impact

Debates about possible causes of diseases and the related and newly introduced “medical arithmetic” engaged physicians throughout the Enlightenment. Ulrich Tröhler (1943–) has argued that a quantitative and critical approach to medicine began in the second half of the eighteenth century in Britain.155 From as early as the 1740s, Monro primus, Cullen and Pringle in Edinburgh, combined their clinical and pathological observations with data on the climatic appearances of diseases: their intended outcome being a natural clas- sification of diseases (nosology) according to the seasons and other causes.156 By the 1780s, Cullen had progressed from Boerhaave’s chemical and medical mechanical conventions to the “reactions of the body”, urging practitioners to combine close empirical observation with systematic reflection.157 Likewise, Fothergill published monthly weather records in The Gentleman’s Magazine from 1751158 and Cleghorn kept weather records in Minorca. By the 1780s, European physicians were abandoning Boerhaave’s aphoristic approach. They increasingly rejected old Galenic dogmas, questioned complex theories of disease and compiled medical and other related scientific data. Careful investigations on the plague presented in Aleppo1, in Patrick’s Treatise of the Plague, and in Aleppo2 were supported by meteorological tables. Weather data was organized with some discipline. Alexander collected weather records for 1742 to 1747,159 and Patrick in 1752 and 1753. Arthur Pollard kept records at the consular house in Aleppo until 1751, when Patrick took the instruments into his own care.160 Their meteorological tables contained

155 Ulrich Tröhler, To Improve the Evidence of Medicine (Edinburgh: Royal College of Physicians of Edinburgh, 2000). 156 George Fordyce, “An Attempt to Improve the Evidence of Medicine”, Medical and Chirurgical Transactions 1 (1793), pp. 242–293. 157 Peter Hanns Reill, Vitalising Nature in the Enlightenment (Berkeley and Los Angeles, CA: University of California Press, 2005), p. 122. 158 Fothergill’s “Observations on the weather and diseases of London”, were republished in Lettsom, Works, vol. 1, pp. 145–240. 159 Aleppo1, 158–189, 167, 210. 160 Aleppo2 ii: 293. Part of Pollard’s register made in Aleppo from 21 September 1747 to 1749, was published at the end of Drummond’s Travels.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access Pathology and Epidemics 267 comparative temperatures and barometer readings.161 The Russells also kept a meticulous catalogue of fevers, gastrointestinal and pulmonary infections and other illnesses, on a month-by-month basis.162 Although Alexander owned that his heavy medical caseload between 1748 and 1751 prevented him com- piling systematic records of epidemic cases,163 he kept “A Diary of the progress of the Plague in 1742, 1743, and 1744” and “Journals of Pestilential Cases”. Infections might be predicted by such means if not controlled.164 These records were assimilated into Aleppo2 though most of the originals are now lost.165 Building upon the two editions of Aleppo,166 Patrick provided “An Appendix, containing Cases of the Plague, and an Account of the Weather during the Pestilential Season” in his Treatise of the Plague,167 partly to support his ideas about the transmission of contagious diseases. Some items have survived: indeed, Patrick’s extensive manuscript notes on “his activities during the plague in Aleppo in the 1760s, sent in the form of a letter to Claud in Edinburgh in 1808 [1805], providing considerable information on Russell’s activities during the plague, in fine condition, 4.5pp folio”, were sold in 2003.168 In addition, Alexander provided a “Register of births and burials between 1742 and 1750”.169 Similar data was collected by Dr Mackenzie in Constantinople in the 1750s.170 Reverend Holloway began a register of births, marriages and

161 Aleppo1, 145–146, 183. Aleppo2 ii: 274, 293, 297. Britain adopted the Gregorian calendar in 1752 which meant that any weather records collected before that date conformed to the Julian calendar. 162 Aleppo1, 190–223; Aleppo2 i: 298–333, 344–345; ii: 123, 125, 129, 301–302, 273–388. 163 Aleppo1, 210. 164 Tore Frängsmyr, J. L. Heilbron and R. E. Rider (eds), The quantifying spirit in the 18th century (Oxford: University of California Press, 1990). 165 Aleppo2 i: 363; ii: Book VI. 166 Aleppo1, 158–589, 167, 210; Treatise of the Plague, pp. 44, 94; Aleppo2 ii: 293, 336–339. 167 Including descriptions of the appalling hot “Simooly” [smūm] winds of the Arabian Desert: Aleppo2 i: 362, citing Ives, Voyage, p. 276; de Thévenot, Travels into the Levant, vol. 2, pp. 54, 116, 135, 157; Six Voyages de Tavernier (Paris, 1676; Paris: F. Maspéro, 1981); Bruce, Travels, vol. 4, pp. 557, 583. 168 Lot 191, Mullock’s Specialist Sporting Auctioneers, Church Stretton, Shropshire, 2003. No reply for a request to the auction house to obtain access has yet been received. 169 Aleppo1, 362–363. [Armstrong], “Art. XII”, p. 4. 170 Letters from Mackenzie to Clephane and to Mead, included “Extracts of several letters of Mordach Mackenzie, MD, concerning the plague at Constantinople”, Philosophical Transactions 47 (1751), pp. 384–395; “A further account of the late plague at Constantinople, in a letter of Dr Mackenzie from thence, of the 23 of April 1752, to John Clephane, MD. FRS.”, Philosophical Transactions 47 (1751), pp. 514–516; and “An account of the plague at Constantinople”, Philosophical Transactions 54 (1764), pp. 69–82.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access 268 Chapter 8 deaths that Dawes later kept between 1758/9 and 1769/70.171 There is information about a charitable trust there too as the Levant Company provided an annual donation of 180 dollars, with “smaller collections made at church services, personal donations, and bequests”. The annual income of this fund over the five-year period ranged between 203 dollars and 293 dollars. As well as charitable donations,172 Dawes’s register records, for example, the death on 19 July 1758 of “Mistress Booth, wife of Thomas Booth, merchant, ‘Both of them of the Anabaptists’.” Other deaths included Anna Sophia Vernon on 10 January 1760; Richard Newton, who was in Aleppo in 1755 but died of an erysip- elas (an acute skin infection) on 3 March 1762; Francis Hughes on 31 October 1762 of malignant fever; and Mistress Elizabeth Edwards, wife of Eleazar, on 6 February 1764, of consumption.173 Between 1750 and 1771, Patrick recorded mortality trends in Aleppo and described, month by month, the course of the plague and related economic conditions during epidemics. Patrick, like Volney and Consul Drummond, observed that during epidemics, few villages were in- habited and fertile areas to the north and west were abandoned,174 whilst un- employed or sick rural migrants swelled the population of Aleppo and added to tensions and unrest. The many deaths and associated social and commercial disruptions were horrific. The importance of medical observation, careful systematic recording of signs, symptoms and therapies and the interpretation of medical and related statistics, were all part of enlightened medicine. Based on the idea of “rational empiricism”, the focus was on meticulous medical observation rather than vague theory. Thus, Aleppo contains information about innovative method- ologies as well as indigenous scientific knowledge and clinical practice; sur- gery; infant conditions;175 the collection of medical, population and mortality statistics;176 infectious diseases and epidemics; and the effects of climate

171 The Marriage Act of 1753, Pedigree Register (1914–1915), pp. 214–217, 225–227, 292–293, 326–327; 4 (1916), p. 385. 172 Laidlaw, Britain in Levant. pp. 105–107, 115, described the Chaplain’s Book of Charitable Donations, 1 January 1765 to 1770. It must have been continued after Dawes’s death in 1770, shortly after leaving or in Aleppo (SP 110/74). The Levant Company provided an annual donation of $180, with “smaller collections made at church services, personal donations, and bequests.” Alms were distributed throughout the year to needy non-Muslims. The annual income of the fund over the five-year period ranged between $203 and $293. 173 Pedigree Register, pp. 214–217. 174 Aleppo2 i: 9; ii: 338–339; Volney, Voyage en Syrie, vol. 2, p. 135; Drummond, Travels, p. 182. 175 Ague: Intermittent Fever, malaria (Rudy, List of Archaic Medical Terms). 176 Aleppo1, 79, 83; Aleppo2 i: 297, 301–302, 344; ii: 79, 83.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access Pathology and Epidemics 269 and famine, nutrition and hygiene, on health and wellbeing. The Russells’ fas- cinating explanations and experiments have lost their significance in the light of more recent advances in medicine but they no doubt did their best to treat patients at a time when clinical practice did not have the benefits of antibiot- ics or sophisticated modern drugs.177 Many infections had an impact on Ottoman history. Epidemics continue in the Levant but what is Aleppo’s significance within epidemiological litera- ture on the Middle East? There have been several modern studies that refer to Aleppo: Jean-Noel Biraben’s Les Hommes et la peste en France,178 Lawrence Conrad on early epidemics in the Muslim world,179 Michael Dols on the social and economic conditions of the Black Death that killed an estimated 75 to 200 million people in Europe especially between 1346 and 1353; and Daniel Panzac’s demographic study of epidemics and public health in the Ottoman Empire.180 More recently, Sam White used Aleppo2 to revise the usual para- digm of diseases in Ottoman history between 1500 and 1800, by using insights from environmental history.181 Apart from the plague, other infectious diseases are generally ignored by modern scholars. Following Alexander’s example in Aleppo, Patrick continued the tradition of discovering, experimenting and testing local medicine and seeking indigenous expertise. In doing so, they both contributed uniquely to a growing corpus of medical knowledge. Professionalism among physicians, ever wish- ing to improve, grew steadily during the Enlightenment throughout Europe – alongside a growing awareness of “new medicine” in the Ottoman Empire – as represented by the two editions of Aleppo, by the Russells’ own medical ar- ticles and Patrick’s Treatise of the Plague. Whilst studying medical aspects of the Russells’ works, one is continually impressed by quite how modern their methods and approaches to medicine appear to be. Compilation of medical statistics and cultural data revolutionized medical knowledge: alongside ex- ploration of alternative medical systems in culturally diverse environments; the interaction of social and environmental factors that influence health and

177 Yet Anton van Leeuwenhoek has been credited with discovering bacteria as early as 1683. 178 Jean-Noel Biraben, Les Hommes et la peste en France et dans les pays européens et méditer- ranéens (Paris: Mouton, 1975). 179 Lawrence Conrad, “Epidemic disease in formal and popular thought in early Islamic Society”, in Terence Ranger and Paul Slack (eds), Epidemics and ideas (Cambridge: Cambridge University Press, 1992), pp. 77–100. 180 Michael W. Dols, “The second plague epidemic and its recurrences in the Middle East 1347–1894”, Journal of the Economic and Social History of the Orient 22 (1979), pp. 162–189. 181 Sam White, “Rethinking disease in Ottoman history”, International Journal of Middle East Studies 42 (2010), p. 552.

Janet Starkey - 9789004362130 Downloaded from Brill.com09/28/2021 03:19:41AM via free access 270 Chapter 8 the spread of disease; a focus on the patient-physician relationships; the explo- ration of alternative materia medica; and an emphasis on preventative medicine, wellbeing, diet and exercise.182 Medical research did not stand in isolation from other disciplines during the Scottish Enlightenment and some of its (often polyglot) practitioners became expert on flora and fauna too (as the following Part outlines). In summary, the Russells’ medical writings shared the same fundamental principles as Julien Offray de La Mettrie (1709–1751), a philosopher-physician of the French Enlightenment and pupil of Boerhaave in Leiden:

First, medicine must be useful, deliberately directed to the prevention and most effective treatment of disease. Second, medicine must be re- formed, and this could be accomplished if medical information were more widely disseminated. Third, medical information must be extended to the public so that they would be able to take better care of themselves and understand some of the issues involved in the treatment of disease. Finally, and most importantly, the public must be informed so that they could participate in medical reform.183

182 In line with their studies in Edinburgh and the work of fellow ex-students. 183 Kathleen Anne Wellman, La Mettrie (London: Duke University Press, 1992), p. 89.

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