Medieval medical responses to the Black Death
The medical response to the Black Death in 1347–1351 was, by modern standards, almost entirely ineffective. Yet it was not, by medieval standards, irrational. Medieval doctors responded to the disease with the best theory they had, with the religious and civic resources at their disposal, and with the practical measures that experience suggested. The result was a complex, sometimes desperate, and often touching body of practice that combined Galenic medicine, Christian devotion, and the first forms of public health. The medieval medical response to the Black Death is the subject of this article.
The clinical forms of the disease are explained in Bubonic vs pneumonic plague: what was the difference?, and the geographical spread is treated in How did the Black Death spread across Europe?. The saints and folk beliefs of the period are surveyed in Late medieval plague saints and folk beliefs. The broader context of the pandemic is set out in the overview of the Black Death.
The Doctors of 1348
The doctors who faced the Black Death in the autumn of 1347 were the inheritors of a medical tradition that went back to the Greek physicians Hippocrates and Galen in the fifth and second centuries BC, transmitted through the Arabic medical tradition of the ninth, tenth, and eleventh centuries, and codified in the great universities of Paris, Bologna, Montpellier, and Oxford in the thirteenth and fourteenth centuries. The training of a medieval doctor typically included seven years of study at a university, with the central texts being the Ars Parva and the Ars Magna of Galen, the Canon of Avicenna, and the Colliget of Averroes. The medical faculty of the University of Paris was, in 1348, the most prestigious in Europe, and its standards were the standards by which other medical faculties measured themselves.
The first major medical text on the Black Death was the Compendium de epidimia of the Montpellier medical master Raymond Chalin de Vinario (c. 1348), who was one of the first doctors to record his clinical observations of the disease. The text was soon followed by the Tractatus de epidimia of the papal physician Guy de Chauliac (c. 1348), the Consilium of the medical faculty of the University of Paris (c. 1348), and the Epidemia of the Sienese physician Tommaso del Garbo (c. 1348). These four texts — and a number of shorter treatises — are the principal medical sources for the Black Death, and they are the texts on which the modern historian of medicine relies for an account of the medieval medical response.
The doctors of 1348 were, in one sense, well equipped. They had a coherent theory of disease, a sophisticated pharmacology, a developed surgical tradition, and a long experience of epidemic disease. They were, in another sense, helpless. They had no effective treatment for the bubonic plague, no germ theory, no antibiotics, and no knowledge of the role of the rat flea in the transmission of the disease. The medical response to the Black Death was, in this sense, a response made from within a system of thought that could not have explained the disease if it had wanted to, and that could not have treated it if it had understood it.
The Great Conjunction of 1345
The immediate cause of the Black Death, in the framework of medieval Galenic medicine, was a corruption of the air, or miasma, produced by the conjunction of Saturn, Jupiter, and Mars in the sign of Aquarius on 20 March 1345. The conjunction was widely reported in the chronicles and in the medical texts of the period, and it provided a ready explanation for the otherwise inexplicable appearance of the plague. The conjunction of 1345 was, in fact, a real astronomical event: the three planets did come close together in the sign of Aquarius in March 1345. The interpretation of the event as the cause of the plague was, of course, wrong, but the interpretation was based on a long and sophisticated astrological tradition, and the doctors of 1348 had no reason to doubt it.
The miasma theory, of which the conjunction was a part, was the standard medieval explanation of epidemic disease. The theory, descending from the Hippocratic treatise On Airs, Waters, and Places and codified by Galen in the second century, held that epidemic diseases such as plague were caused by poisonous airs that were breathed in by the patient or that entered the body through the pores of the skin. The miasma was produced, in turn, by a particular conjunction of climatic, terrestrial, and astronomical factors: the decay of organic matter, the eruption of volcanoes, the conjunction of the planets, the corruption of the air after earthquakes. The theory was not absurd, given the state of medical knowledge, and the prescription of strong-smelling substances as protection was, in some cases, of marginal benefit: camphor is in fact a mild antiseptic, and the burning of aromatic woods may have helped to mask the smell of decomposing bodies.
The medical theory of the Black Death was, in this sense, a coherent system. The disease was caused by corrupted air. The corrupted air was produced by the conjunction of 1345. The cure was to expel the corrupted humors through bleeding, purging, and sweating, and to protect the patient from further exposure to the bad air through the burning of aromatic herbs, the application of vinegar, and the use of strong-smelling pomanders. The system was wrong, but it was not incoherent. The doctors of 1348 were not quacks: they were the best-trained medical professionals of their day, working within a tradition that had been the most advanced in the world for a thousand years.
The Lancet and the Poultice
The standard medical response to a patient with bubonic plague in 1348 was to bleed the patient immediately, often by opening a vein near the bubo, in the hope of draining the corrupted humors. If bleeding did not work, purges were administered, often including strong emetics and laxatives. The patient might also be subjected to “sweating” treatments, in which he or she was wrapped in heavy blankets and given hot drinks to induce a profuse sweat. The idea was to expel the corrupted matter through the pores of the skin.
The treatments of the medieval doctors were, in retrospect, often harmful. Bleeding a patient who was already weak from fever and dehydration accelerated the decline. Purges of strong emetics and laxatives caused further fluid loss. Sweating treatments, especially in the absence of clean water, exposed the patient to additional infection. The mortality of patients who were subjected to the full battery of medieval treatments was probably higher than the mortality of those who were simply left alone, and some medieval doctors were aware of this. The Consilium of the University of Paris of 1348, drawn up by the medical faculty in response to a request from Philip VI of France, actually advised against excessive bleeding and recommended that doctors should focus on supporting the patient’s natural resistance rather than attacking the disease directly. The Consilium is, in this sense, one of the most important documents of medieval medicine: a moment at which the leading medical faculty of medieval Europe was prepared to recommend restraint in the face of a disease for which it had no effective treatment.
The surgical response to the buboes was, in many cases, the most aggressive. Some doctors lanced the buboes to drain the pus, in the hope of releasing the corrupted matter. The practice is described in the Chirurgia of Guy de Chauliac (1363), the most important surgical text of the Middle Ages, and it was widely used. The lancing of the buboes was painful and, in most cases, ineffective, but it was based on a reasonable principle: the bubo was a collection of fluid, and the drainage of the fluid was, in the theory, the drainage of the corrupted matter. The treatment was used well into the sixteenth century, and it is one of the few elements of the medieval medical response to the plague that survived into the early modern period.
Pistoia, Venice, Ragusa: The Birth of Public Health
The most lasting practical innovation of the Black Death was the development of public health measures designed to slow or contain the spread of the disease. The first city to develop a systematic response was Pistoia, which appointed a permanent sanità, or health board, in 1348. The sanità was a committee of laymen, advised by doctors, with the power to isolate infected households, to restrict the movement of travellers, to seize the property of the dead, and to burn the clothing and bedding of plague victims. The Pistoian model was quickly imitated by Venice, Florence, Milan, and other Italian cities.
The most famous of the public health measures was the quarantine, the quaranta giorni — the forty-day period of isolation imposed on incoming ships, travellers, and goods. The first recorded quarantine was imposed by the port of Ragusa (modern Dubrovnik) in 1377, when the city council ordered that all travellers arriving from plague-infected areas must spend thirty days on the island of Mrkan or in the town of Cavtat before being admitted to the city. The thirty-day period was extended to forty days in 1392, and the term quaranta giorni entered the European languages as the word for the practice. Ragusa was followed by Venice in 1403, by Marseille in 1383, and by a number of other Mediterranean ports in the fifteenth century.
The public health measures of the Italian cities were not, in the first instance, a response to the Black Death alone. The cities had a long history of public health administration, going back to the medieval commune, and the sanità was an extension of the existing structures of urban government. The measures were, however, transformed by the experience of the Black Death. The permanent sanità boards, the lazarettos, the quarantines, the cordons sanitaires, the burning of the clothing of the dead — all of these became permanent features of the urban landscape, and they were the basis of the public health systems of the early modern period. The Italian model was, in this sense, the first model of modern public health, and it was the model that was eventually adopted by every European state.
Faith, Saints, and the Carriers of Disease
The medical response to the Black Death was inseparable from the religious response. Most medieval people, including most medieval doctors, believed that the plague was a manifestation of divine wrath, sent to punish the sins of humanity. The appropriate response, in this framework, was repentance, prayer, and the intercession of the saints. Plague processions, in which the population of a town would march behind the relics of the local saints, were a common response. Masses were said, vows were made, and pilgrimages were undertaken in the hope of staying the divine hand.
A wide range of saints were invoked against plague. Saint Roch, a French pilgrim who was believed to have healed plague victims, became one of the most popular. Saint Sebastian, the Roman soldier martyred by arrows, was another common intercessor. Saint Christopher, traditionally invoked by travellers, was believed to protect against sudden death. The cult of the Virgin Mary, especially under the titles of Our Lady of Sorrows and Our Lady of Mercy, expanded rapidly in the wake of the Black Death. The saints of the plague, and the folk practices that surrounded them, are surveyed in Late medieval plague saints and folk beliefs.
Alongside the religious response, a network of charitable institutions emerged to care for the sick and the dying. Confraternities of laypeople organised the burial of the dead, the distribution of bread to the poor, and the visitation of the sick. The Florentine lay confraternity known as the Compagnia di Santa Maria della Croce al Tempio, founded in 1348, became closely linked to the hospital of Santa Maria Nuova — itself founded earlier, in 1288, by Folco Portinari — which survives in modified form to the present day. Hospitals, many of them founded in the wake of the Black Death, took in the destitute and the dying.
The persecution of the Jews in the wake of the Black Death was, in part, a consequence of the medical theory. The Jews were accused of poisoning the wells, and the accusation was supported by confessions extracted under torture. The persecution of the Jews in the wake of the Black Death is examined in Jewish persecution and the spread of plague. The persecution of witches, lepers, and other minorities was also, in part, a consequence of the folk belief that the disease was caused by human agents, and the wave of persecution in the late fourteenth century was a direct consequence of the Black Death.
The Limits of the Medieval Response
The medieval medical response to the Black Death combined the best theory of the day, the religious practices of the church, and the practical measures of public health that experience suggested. The result was a complex and often desperate body of practice that did little to save the lives of the sick but that laid the foundations for the sanitary institutions of the early modern period. The plague was the first disease to be confronted by a system of public health, even though the science that would eventually explain it lay centuries in the future.
The limits of the medieval response are, however, important to acknowledge. The doctors of 1348 could not have cured the disease, and the public health measures could not have contained it. The mortality of the Black Death was a function of the biological properties of the Yersinia pestis bacterium, the absence of acquired immunity in the European population, and the absence of any effective treatment. The medieval response to the disease was, in this sense, a holding operation: a set of measures designed to limit the spread of the disease, to care for the sick, and to keep the social and religious fabric of the community together in the face of a catastrophe that could not be averted.
The response was, on the whole, less successful than the responses of the seventeenth and eighteenth centuries to later outbreaks of plague, in which the cordon sanitaire, the lazaretto, and the plague doctor were more systematically applied. But the medieval response was the first response, and it was the response that established the framework within which all later responses were organised. The plague was, in this sense, the founder of European public health, and the medieval response to the plague was the foundation of the modern sanitary state.
References
- Park, Katharine. Doctors and Medicine in Early Renaissance Florence. Princeton University Press, 1985.
- Siraisi, Nancy G. Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice. University of Chicago Press, 1990.
- Cipolla, Carlo M. Public Health and the Medical Profession in the Renaissance. Cambridge University Press, 1976.
- Cosmacini, Giorgio. Storia della medicina e della sanità in Italia. Laterza, 1987.
- McVaugh, Michael R. Medicine Before the Plague: Practitioners and Sick Patients in the Crown of Aragon, 1285–1345. Cambridge University Press, 1993.