The Greatest Benefit to Mankind: A Medical History of Humanity

This proliferation provoked attempts by princes and city authorities at regulation and ‘protection’. In the Kingdom of Sicily the royal physician took charge of licensing, while in the 1340s the Aragonese King Peter licensed Jewish practitioners who had been denied medical degrees from Christian universities. Church authorities often licensed midwives, on the grounds that their morals needed to be impeccable.

Urban expansion also explains the emergence, initially in northern Italy, of community-employed public physicians. The earliest known public contracts for such medici condotti were at Reggio in 1211 and in neighbouring Bologna in 1214, where the appointee was to treat soldiers as well as citizens. Contracts typically imposed a residence requirement, balanced the doctor’s private and public duties, and set scales of fees. Especially in time of plague, the civic doctor was to assist at inquests and trials, to attend hospitals, and to tend injuries resulting from judicial torture.

This system spread. By 1300, public physicians were found in all the large towns of northern Italy; a century later the office was almost universal in northern and central Italy and in the Venetian territories in Dalmatia and Greece, and it had also been adopted in major centres in Provence, Aragon and Valencia. By 1500 civic doctors were being appointed in northern France, Flanders and many German cities, though Britain lagged behind.

Meanwhile rising urban populations contributed to overcrowding and worsening sanitary problems, due to the contamination of drinking water and food, waste accumulation and the keeping of livestock. Water began to be piped into towns, and by 1300 Bruges had built a municipal water system. Many towns paved their main thoroughfares; every large house in Paris was required to have a chamber draining into the sewers, and Milan passed ordinances for cesspools and sewers. Some German cities prohibited pig-pens facing onto the street; municipal slaughterhouses were established, and cities also tried to monitor food markets and curb river pollution. For example, tanners were not allowed to wash their skins or dyers to dump their waste in public waters. Nonetheless filth began to pose mounting threats. Plague struck in the fourteenth century (see below) and typhus from the close of the fifteenth.

LEPROSY

Certain diseases loomed large both in reality and in the public imagination, notably leprosy, now called Hansen’s disease after Armauer Hansen (1841–1912), the discoverer of the bacillus Mycobacterium leprae. Its physical symptoms – scaly flesh, mutilated fingers and toes and bone degeneration, in short ‘uncleanliness’ – made it seem a living death and led to deeply punitive attitudes. The disease has a puzzling history. From as early as 2400 BC Egyptian sources contain references to a skin condition interpreted as leprosy, and 900 years later, the Ebers papyrus mentions a leprous disease seemingly confirmed by Egyptian skeleton evidence. True leprosy probably existed in the Levant from biblical times, but the term was also used for various dermatological conditions producing disfiguring ulcers and sores.

Leprosy became highly stigmatized. Authorized by ancient Levitical decrees, leper laws were strict in medieval Europe. They were forbidden all normal social contacts and became targets of shocking rites of exclusion. They could not marry, they were forced to dress distinctively and to sound a bell warning of their approach. According to the liturgical handbook, the Sarum Use, in thirteenth-century England,

I forbid you ever to enter churches, or go into a market, or a mill, or a bakehouse, or into any assemblies of people.

I forbid you ever to wash your hands or even any of your belongings in spring or stream of water of any kind …

I forbid you ever henceforth to go out without your leper’s dress, that you may be recognized by others …

I forbid you to have intercourse with any woman except your wife…

I forbid you to touch infants or young folk, whosoever they may be, or to give them or to others any of your possessions.

I forbid you henceforth to eat or drink in any company except that of lepers …

They were segregated in special houses outside towns, lazarettos, following the injunction in Leviticus that the ‘unclean’ should dwell beyond the camp. There was also a leper mass, conducted with the victim in attendance, declaring the sufferer to be ‘dead among the living’, and the 1179 Lateran Council ordered them cast out from society, with their own burial places. The only consolation the Church gave was to interpret the leper’s suffering as a purgatory on earth, destined to bring swifter reward in heaven. God, proclaimed de Chauliac, loved the leper; after all, did not the Bible (Matthew 8:3) show Jesus extending his hand, saying ‘be thou clean’?

Leprosy provided a prism for Christian thinking about disease. No less a religious than a medical diagnosis, it was associated with sin, particularly lust, reflecting the assumption that it was spread by sex. In The Testament of Cresseid by Robert Henryson (fl. 1470–1500), the heroine is punished by God with leprosy for her lust and pride. Lepers were thus scapegoated with Jews and heretics in what historians have called a ‘persecuting society’.

From the eleventh century there was a rapid surge in the number of hospitals built to house lepers. By 1226 there may have been around 2,000 in France alone, and in England about 130. By 1225 there were a staggering 19,000 leprosaria in Europe, offering shelter while enforcing isolation. Yet by 1350 leprosy was in decline. The epidemiology of that watershed is much disputed: some have speculated that the Black Death killed so many that the disease died out, others that it might be connected with the rise of tuberculosis, which has a similar but more aggressive pathogen; the TB bacillus could have elbowed out the leprosy. But though the disease waned, its menace remained, becoming a paradigm for later diseases of exclusion, and for persecution generally. Leprosaria were used for the poor and those suspected of carrying infectious diseases. Some became hospitals: on the then outskirts of Paris, the Hôpital des Petites Maisons, near the monastery of St Germain des Prés, founded as a leprosarium, was used for the mentally disordered and for indigent syphilitics. St Giles-in-the-Fields, then just outside London, was a lazaretto and later a hospital, as were the hospitals for incurables built outside Nuremberg.

PLAGUE

The Black Death is the most catastrophic epidemic ever to have struck Europe, killing perhaps twenty million people in three years. Absent from Europe for eight hundred years since the plague of Justinian, it was endemic for the next three centuries. The Great Pestilence of 1347–51 probably originated in China; in 1346 it migrated from beyond Tashkent in central Asia to the Black Sea, where it broke out among the Tatars fighting Italian merchants in the Crimea. A chronicler tells how the Christians took refuge in the citadel at Kaffa (Feodosia), where they were besieged. Plague forced the Tatars to raise the siege, but before withdrawing they invented biological warfare by catapulting corpses of plague victims over the citadel walls, causing the disease to flare among the Christians. When they in turn escaped, it travelled with them into the Mediterranean, breaking out in Messina and Genoa and raging through the rest of Europe. According to Fra Michele di Piazze,

In the first days of October 1347, twelve Genoese galleys fleeing before the wrath of our Lord over their wicked deeds, entered the port of Messina. The sailors brought in their bones a disease so violent that whoever spoke a word to them was infected and could in no way save himself from death … Those to whom the disease was transmitted by infection of the breath were stricken with pains all over the body and felt a terrible lassitude. There then appeared, on a thigh or an arm, a pustule like a lentil. From this the infection penetrated the body and violent bloody vomiting began. It lasted for a period of three days and there was no way of preventing its ending in death.

Within a couple of years, plague killed around a quarter of Europe’s population – and far more in some towns; the largest number of fatalities caused by a single epidemic disaster in the history of Europe. This provoked a lasting demographic crisis. Thousands of villages were abandoned, and by 1427 Florence’s population had plummeted by 60 per cent from over 100,000 to about 38,000. A Europe which had been relatively epidemic-free turned into a crucible of pestilences, spawning the obsessions haunting late medieval imaginations: death, decay and the Devil, the danse macabre and the Gothic symbols of the skull and crossbones, the Grim Reaper and the Horsemen of the Apocalypse.

Boccaccio (1313–75) gave the most graphic account of plague in the Decameron, a collection of tales related by a group of young men and women who had fled Florence to escape it (the regular advice was ‘flee early, flee far, return late’). Noting that most of the afflicted died within three days, he recorded:

Such was the cruelty of heaven and to a great degree of man that between March [1348] and the following July it is estimated that more than 100,000 human beings lost their lives within the walls of Florence, what with the ravages attendant on the plague and the barbarity of the survivors towards the sick.

So virulent was the plague, ‘that the sick communicated it to the healthy who came near them, just as a fire catches anything dry or oily near it’ (a sign that ordinary people regarded it as contagious). ‘How many valiant men, how many fair ladies, breakfasted with their kinsfolk and that same night supped with their ancestors in the other world.’

Social breakdown followed. In Siena, wrote one survivor,

Father abandoned child, wife husband, one brother another … none could be found to bury the dead for money or friendship … they died by the hundreds, both day and night, and all were thrown in ditches and covered with earth. And as soon as those ditches were filled, more were dug. And I, Agnolo di Tura … buried my five children with my own hands.

Though epidemiological controversies have raged, the Black Death was almost certainly bubonic plague, caused by transmission of the bacillus Yersinia pestis from rats to humans via fleas (notably Xenopsylla cheopis). When the bacillus enters the body through the bite of an infected flea (it can disgorge up to 24,000 in one bite), the disease follows the pattern called bubonic. After a six-day incubation, victims suffer chest pains, coughing, vomiting of blood, breathing troubles, high fever and dark skin blotches caused by internal bleeding (hence the name Black Death), as well as hard, painful egg-sized swellings (buboes) in the lymph nodes in the armpit, groin, neck and behind the ears. Restlessness, delirium, and finally coma and death generally follow. Not all the features familiar in contemporary Asia match those recounted in medieval chronicles. The swift onset suggests that some direct human-to-human transmission also took place, perhaps in the form of pneumonic plague, spread by droplet infection.

Many explanations were inevitably offered: God in His wisdom had sent plague to punish mankind for its sins; it might be the result of planetary conjunctions; amongst the ‘natural causes’, alterations in the environment could cause a ‘pestilential atmosphere’ resulting from effluvia, vapours from stagnant pools, dungheaps, decaying corpses, the breath of sufferers themselves – or poisoning of the air by ‘enemies’ such as Jews. Laymen like Boccaccio referred to contagion, but most medical theorists, loyal to their Greek learning, stood by constitutional factors: if the body was robust, illness should not result; if not, one would sicken and die.

Responses depended upon which theory was accepted. If the plague was truly God-sent, only prayer and fasting could be effective. This encouraged flagellant bands to trudge from town to town, whipping each other, hoping by their lashings and denunciations of Jews and sinners to propitiate divine wrath; which in turn sparked persecution of Jews, who were accused of poisoning the wells. In Basel, Jews were penned up in a wooden building and burnt alive; 2000 were said to have been slaughtered in Strasbourg and 12,000 in Mainz; while in July 1349 the flagellants led the burghers of Frankfurt into the Jewish quarter for a wholesale massacre. But, however pious, the flagellants themselves posed a serious threat to public order by creating panic and challenging authority, leading Pope Clement VI to prohibit them.

Seeking to protect themselves with long leather gowns, gauntlets, and masks with snouts stuffed with aromatic herbs, physicians put the accent on individual treatment, on the assumption that plague involved atmospheric putrefaction. They recommended sniffing amber-scented nosegays and pomanders and administering strong-smelling herbs – aloes, dittany, myrrh and pimpernel, all supposed to have cleansing properties, to say nothing of those princes of pharmacy, mithridatium and theriac. Fires should be lit and rooms fumigated with aromatic wood or vinegar. Writing in 1401, the Florentine doctor Lapo Mazzei (1350–1412) suggested ‘it would help you to drink, a quarter of an hour before dinner, a full half-glass of good red wine, neither too dry nor too sweet.’

Faced with plague, physicians had no power to effect public-health measures; that was the magistrate’s business. In Venice a committee of three nobles laid down burial regulations, banning the sick from entering the city and jailing intruders. In Milan, the council sealed in the occupants of affected houses and left them to die (perhaps this draconian measure worked: Milan had only a 15 per cent death rate). In Florence a committee of eight was given dictatorial powers, though ordinances requiring the killing of dogs and cats ironically removed the very animals that might have contained the rats. At that time, however, no one had any reason to suspect rats.

Secular and religious strategies were sometimes at odds. In 1469, despite the risks of congregating in large numbers, the civic authorities in Brescia allowed the Corpus Christi procession to go ahead because deliverance, hoped the pious, would come through divine intervention. By contrast, in time of plague the Venice Health Board banned preaching, processions and feast-day assemblies. Churches were locked, and in 1523 and 1529 even the shrine of St Roch, a popular intercessor against plague, was shut.

Certain routines became standard. The committees appointed to co-ordinate public health measures began to remove the sick to leper houses beyond city limits (hence ‘lazaretto’ came to mean a plague hospital), while also establishing a system of exclusion, banning persons or goods from entering or leaving. Such measures were adopted throughout Italy. In 1377 Ragusa (Dubrovnik, Croatia) instituted a regular thirty-day isolation period on a nearby island for all arriving from plague-infected areas; in 1397 this was increased to forty, thus becoming a true quarantine (quarantenaria, forty days). Marseilles took similar action in 1383; Venice imposed quarantine measures in 1423; in 1464 Pisa followed and Genoa three years later.

Before the fifteenth century such health boards, composed of nobles and officials, were ad hoc creations. In Milan, however, a permanent magistracy ‘for the preservation of health’ was established around 1410, with (by 1450) a staff of a physician, surgeon, notary and barber, two horsemen, three footmen and, sensibly, two grave-diggers. Doctors acted not as full members of such boards but as advisers. Other Italian cities followed; in 1486, Venice appointed a permanent Commission of Public Health, consisting of three noblemen; Florence set up a similar commission of five in 1527, and Lucca one of three in 1549. Bills of Mortality were initiated in Milan, listing names and causes of death. Health Boards extended quarantines and the closing of borders, and health passes were introduced. In these respects, north European towns lagged behind Italy by more than a century.

The regulation of markets, streets, hospitals and cemeteries, the control of beggars, prostitutes and Jews – in short, public health measures – fell under the health boards. Resentment was expressed about their cost and powers, especially since economic disaster was almost inevitable once plague had been declared official, with commerce and travel suspended and markets closed.

Obliquely, therefore, medical practitioners became more involved in public administration. Midwives, too, performed policing functions. Laws required them to report illegitimate births, and to press unmarried mothers for the names of the father, so as to secure financial support for the babies. The oaths sworn by English midwives seeking a bishop’s licence included promises to extract the truth about paternity and to refuse requests for secret births.

MADNESS

Alongside leprosy and plague, another condition of public concern was insanity. Madness remained particularly disputed. On Galen’s authority, medical writers distinguished four main categories: frenzy, mania, melancholy and fatuity, each the result of a particular humoral imbalance. Folklore believed the moon caused lunacy; theology saw it as a consequence of diabolical possession or sorcery. Some viewed it as divinely inspired, perhaps involving the gift of tongues; others praised the innocence of the village idiot; while troubadours might sing of tragic love-madness.

Nor was there agreement over remedies. Some advocated drugs and bleeding to sedate the demented and evacuate peccant humours. Shock treatment might be tried, such as hurling a maniac into a river. For demoniacal possession, there was exorcism, while certain saints had the power to cure madness. Three shrines enjoyed a special reputation: St Mathurin at Larchant and St Acairius at Haspres (both in northern France), and St Dymphna at Geel in Flanders. A hospice built there to house the mentally ill proved too small and many were lodged in village households. From this a special ‘family colony’ developed, in which the mentally ill were tended by the villagers. The Geel community still exists.

Public attitudes towards the insane were mixed. German municipalities sometimes expelled idiots or insane persons, whipping them out of town – though the celebrated ‘ship of fools’ is not a reality but a literary conceit, symbolizing humanity’s follies. The insane were cared for in monasteries; various towns had madmen’s towers (Narrentürme); in Paris, special cells were set aside at the Hôtel Dieu; and the Teutonic Knights’ hospital at Elbing had a madhouse (Tollhaus). Specialized hospitals began to appear, notably under the influence of Islam in Spain: Granada (1365), Valencia (1407), Zaragoza (1425), Seville (1436), Barcelona (1481) and Toledo (1483). The priory of St Mary of Bethlehem in London, founded in 1247, was by 1403 housing six men ‘deprived of reason’; it developed into the notorious Bedlam. Such moves towards incarceration were counterbalanced by the image of the mad person as a holy fool, while in the ‘feast of fools’ medieval society came to terms with mental alienation through the carnival notion of the world turned upside down – madness as dionysian release.

The insane also became linked to witchcraft, with demonic possession serving as an explanation for deranged behaviour. Haunted by plague and heresy, the late medieval church warned against the Devil and his minions; women were considered particularly susceptible to Satan; and during the next 300 years the witch-craze seized Europe, leading to the execution, often after judicial torture, of upwards of 50,000 victims, mainly women (the figure of nine million burnings, often cited in feminist writings, is pure fantasy).

An individual of whom much is known is the English mystic, Margery Kempe (b. 1393). A wealthy woman who owned a brewery in King’s Lynn, she fell victim to puerperal insanity and began to behave oddly. Undertaking pilgrimages to Jerusalem, Rome and Spain, she described her spiritual experiences. The Book of Margery Kempe (c. 1423), perhaps the very first English autobiography, reveals the contested borderland between illness and religious experience. To some of her companions she was a sick woman, indeed a confounded nuisance with her non-stop wailings; to others, she was the mouthpiece of God – or was possessed by the Devil. ‘Many said’, she wrote,

there was never saint in heaven that cried as she did, and from that they concluded she had a devil within her which caused that crying. And this they said openly, amid much more evil talk. She took everything patiently for our Lord’s love, for she knew very well that the Jews said much worse of His own person than people did of her, and therefore she took it the more meekly.

WOMEN

Margery Kempe’s difficulties derived in part from perceptions of her gender; certain disorders were associated with women and their reproductive systems. Giving birth is depicted in medieval texts as an all-female business, the mother being supported by relatives, neighbours and a midwife. Midwives rose in status, as some town councils paid them to act in an official capacity in cases involving female illness, obstetrics and infant care. They were called upon to test for virginity or sterility, and to certify infant deaths.

A few obstetrical texts were directed to female readers, and male writers discussed gynaecological problems and prescribed remedies for female sexual disorders, advising not least on contraception. The Treasury of the Poor, ascribed to Peter of Spain (later Pope John XXI), gave over a hundred prescriptions concerning fertility, aphrodisiacs and contraceptives, presumably derived from popular tradition. Medical attitudes towards sex were far from puritanical, for sexual release was regarded as requisite for humoral balance, and female orgasm was widely believed essential for conception.

Female healers abounded, sometimes learning their craft from a male member of the family, and a few women wrote medical texts. Hildegard of Bingen (1098–1179), who had been put in a convent at the age of eight and began having religious visions soon after, practised medicine in her role as abbess of Rupertsberg. Her main work was the Liber simplicis medicinae (c. 1150–60) [Book of Simple Medicine], on the curative powers of herbs, stones and animals; she also wrote on the natural causes of diseases. These texts summarize traditional lore concerning the medical uses of animals, vegetables and minerals, advising treatments on the principle of opposites, while for terrible diseases like leprosy she commended exotic remedies involving unicorn liver and lion heart. Herbs were God’s gifts; either they would cure or the patients ‘will die for God did not will that they should be healed’.

Another acclaimed woman healer is more enigmatic. Obstetrical writings and other treatises of women’s disorders are attributed to a certain Trotula, said to be a female member of the medical school of Salerno during the twelfth century; but ‘Trotula’, anglicized as ‘Dame Trot’, was more likely a male writing in drag. Texts called The English Trotula long circulated, containing advice on conception, pregnancy and childbirth and motherhood (nursing mothers should avoid highly salted or spiced food).

A few female healers were accepted into the Florentine practitioners’ guild, and English records show women called ‘leech’ or ‘medica’; at St Leonard’s Hospital, York, a Sister Ann was described in 1276 as a medica. But women were excluded in the later Middle Ages, marginalized by professional conflicts and guild restrictive practices. In 1421, the English physician Gilbert Kymer and his cronies petitioned Parliament to ban women from practising. The limitation of medical and surgical practice to those who had received a university training or were enrolled in a guild tended to confine women to nursing, midwifery and home physic.