Modern medical science, if a gross over-generalization may be forgiven, began with Hippocrates. It was he who first conceived ill health, not as a series of unrelated and essentially inexplicable catastrophes but as an orderly process calling on each occasion for examination of symptoms, diagnosis of malady and prescription of cure. For any study of the Black Death his importance is paramount since he was the first student of epidemiology and the first to distinguish between epidemic and endemic diseases. In his First and Third Books of Epidemics and the four volumes of notes compiled either by Hippocrates himself or by his son he set out to analyse the factors which led to a disease settling in any given area and becoming endemic. The next stage was to define and explain the causes, climatic, meteorological or latent within the body of man himself, which provoked a subsequent epidemic outburst. It was his particular concern to work out a relationhip between each type of epidemic and the different environmental conditions in which it flourished. This ‘katastasis’, as he called it, was, it seemed to him, best established on astronomical evidence – a red herring which Hippocrates himself might in time have transcended but which was to bedevil medical research for many centuries.
The main flaw in the monumental labour of Hippocrates was that he had insufficient data from which to draw valid conclusions. He deduced, for instance, that spells of warm, moist weather were, in themselves, conducive to ill health; a thesis reasonable enough where malarial regions were concerned but irrelevant if not positively misleading when applied to England. His great achievement was to have provided a blue-print for research on which subsequent generations should have worked. The tragedy is that the vast compilation of case histories, on which a serious study of epidemiology could alone have been based, was not made by his successors. After the death of Hippocrates in 377 BC, medical science slumbered for five hundred years; it awoke only to find itself rigidified by the misplaced formalizing genius of Galen of Pergamos.
Galen was one of the outstanding intellects of his age and a great experimental physiologist. But, when it came to epidemiology, rather than work from the Hippocratic base and accumulate fresh data from which empirically to establish new and constructive theses, he instead elected to devise an inflexible theoretical pattern which left no room for further research or original thought. He lived through a major epidemic of bubonic plague but the phenomenon was in no way reflected in his work. To attempt to summarize Galen’s complicated and, within his own terms of reference, logically faultless theorizing would be to reduce it to a parody. Suffice it to say that he believed ill health to depend on the interaction of temperament, the constitution of the atmosphere and certain other factors such as excessive or ill-judged eating and drinking. Temperament and constitution in their turn depended on the blending of the elementary qualities and any failure to achieve perfect balance led to one of a number of possible discords. The permutations on these factors were developed into an intricate mathematical pattern: a computer into which the details of any case could be fed and a logically satisfactory explanation provided.
Unfortunately, though the logic might be impeccable, its relevance to anything so mundane as the prevention or cure of plague was sadly tenuous. What was worse, the medieval physician believed that Galen had said the last word on epidemics and that any further research was unnecessary if not positively disrespectful to the teachings of the master. And yet the teachings of the master themselves were in doubt since the original texts had been largely lost and doctors in the West for several centuries worked almost exclusively from inadequate Latin versions of Arabic translations of Hippocrates and Galen. The result was an Arabic-Latin literature, in Dr Singer’s description,
…generally characterized by the qualities most often associated with the words ‘medieval’ and ‘scholastic’. It is extremely verbose and almost wholly devoid of the literary graces. An immense amount of attention is paid to the mere arrangement of the material, which often occupies its author more than the ideas that are to be conveyed. Great stress is laid on argument, especially in the form of syllogism, while observation of nature is entirely in the background…. Lip-service is often paid to Hippocrates, but his spirit is absent from these windy discussions.{122}
Nurtured on such material it is hardly surprising that medical science did not flourish in the Middle Ages. ‘The Dark Ages for Medicine,’ wrote Dr Singer, ‘began at the death of Bede in 753’.{123} They did not end until long after the Black Death had run its course. But the failings of the fourteenth-century doctors should not be exaggerated nor their limitations presented as grotesque extravagances. Ill-informed and unimaginative they might have been but there was, on the whole, surprisingly little of the:
Watres rubifiying, and boles galle,
Arsenyk, sal armonyak, and brymstoon,
And herbes koude I telle eek many oon,
As egremoyne, valerian, and lunarie.[1]
which were the stock-in-trade of Chaucer’s alchemist.
The situation of medicine was not helped by the stern determination of the medieval churchman to keep the physician in his place. What Professor Gurlt described as ‘that fatal exaggeration which enthroned theology not merely as mother but as Queen of all the sciences’,{124} ensured that the doctor would play a secondary role. In the sick room it was the priest who took the lead and the doctor who humbly offered his services once the praying was over. Before he even treated a patient the doctor was supposed to establish whether he had first confessed; if he had not, then medicine would have to wait its turn. Sometimes the doctor would manage to assert himself but, in general, the more eminent the invalid, the more likely it was that he would find himself thrust into the back row behind a bevy of churchmen and courtiers. When the disease worked quickly a doctor might not even be admitted to his patient’s bedside until death was imminent or had actually occurred.
But the Church, by the stranglehold which it had on every field of education, ensured that the invalid would have gained little even if the doctor had been given a freer hand. All medical teaching at the universities was on lines laid down by the Church and consisted mainly of the reading of outmoded texts with a brief and usually misleading ‘interpretation’ by the professor. Surgery was the poor relation of an anyhow impoverished science. In 1300, Boniface VIII published a Bull forbidding the mutilation of corpses. His object was to check the excesses of relic hunters but, incidentally, he dealt a crippling blow to would-be anatomists. Soon afterwards the Medical Faculty of Paris formally declared itself an opponent of surgery. At Montpellier, supposed to be among the most enlightened of the medical schools, there was one practical anatomy lesson every two years. This long and eagerly awaited occasion consisted merely of the opening of an abdomen and a cursory exposition of its contents. It was not till the end of the fifteenth century that Sixtus IV authorized the practice of dissection and even then specific authority had to be obtained on each occasion.
Given such handicaps it would have been miraculous if the medical profession had met the Black Death with anything much more useful than awe-struck despair. Their efforts were as futile as their approach was fatalistic. Not only were they well aware that they could do little or nothing to help but they considered it self-evident that an uncharitable Deity had never intended that they should. ‘The plague’, wrote Gui de Chauliac, one of their most distinguished and, incidentally, successful practitioners, was ‘shameful for the physicians, who could give no help at all, especially as, out of fear of infection, they hesitated to visit the sick. Even if they did they achieved nothing, and earned no fees, for all those who caught the plague died, except for a few towards the end of the epidemic who escaped after the buboes had ripened.’{125} A doctor not prepared to visit the sick must, of course, labour under a singular disadvantage but de Chauliac was certainly right in his contention that, from the point of view of the infected, it made little difference. Nothing in the medical literature which survives suggests that the treatment of the doctors, though it may sometimes hav
e eased a patient’s sufferings, can have been directly responsible for a single cure.
The views and activities of the doctors are reasonably well known through the plague tractates which they left behind them. Sudhoff’s Archives{126} already reproduce well over two hundred and eighty of these. Many relate to other phases of the great pandemic but seventy-seven were written before 1400 and at least twenty before 1353. The majority of the most important studies relating to the Black Death have been analysed by Dr Anna Campbell in her invaluable work, The Black Death and Menof Learning.{127} The preamble to the Report of the Faculty of Medicine at Paris demonstrates admirably the vague, hopeless search for arcane solutions which appeared again and again in the tractates: ‘Upon seeing effects whose cause is concealed even from the most highly trained of intellects, the mortal mind must ask itself, especially as there is in it an innate desire for appreciation of the good and of the true, for what reason everything seeks good and desires knowledge…’
But the windy nothingness of this somewhat unhelpful speculation was by no means typical. There was much shrewd observation and a certain amount of common sense and sound judgement in the recommendation of measures which, though no more than palliatives, still did more good than harm. Certainly there was a depressing readiness to stress that flight was the only possible defence against the plague or to argue that, if flight were impossible, there had better be immediate recourse to prayer. But the patient was also given a certain amount of guidance on how he should conduct himself. It seems unlikely that much confidence was inspired among those threatened or afflicted by the plague but some people must at least have been given a ray of hope and a feeling that they were not entirely helpless in the face of destiny.
Differences of opinion between the experts were frequent. Simon of Covino{128} considered that the pregnant woman and, even more, ‘those of fragile nature’ would succumb and that no doctor could help them. The undernourished pauper would be the first to go – a reasonable conclusion which the Medical Faculty, however, rejected, claiming that those ‘whose bodies are replete with humours’ were the most vulnerable. Ibn Khātimah{129} agreed with the Faculty. People of ‘hot, moist temperament’ were the most exposed; the ultimate in peril was to be a stout young woman with a taste for lechery.
There was more agreement on the best place to live so as to avoid the plague. Seclusion, obviously, must be a first priority. After that, the problem was how to keep out of the way of the dreadful miasma, the infected air which, borne generally by the south wind, carried death from land to land. A low site, sheltered from the wind, was of course desirable. The coast was to be shunned; with good reason because of the threat from shipborne rats though the danger was visualized by the tractators as corrupt mists creeping lethally across the surface of the sea. Marsh lands were not to be recommended for here too rose the killing mist. Houses should face north; windows preferably be glazed or covered with waxcloth.
Even in the most prosperous practices – and where there was no prosperity there was generally no doctor – the doctor recognized that many of his clients would not be able to flee to remote spots where they might hope to escape the plague. Rules had to be laid down for the conduct of life in a plague-stricken area. If infection was carried by corrupted atmosphere then what was needed was something to build up counter-bodies within the air. Dry and richly scented woods were to be burnt: juniper, ash, vine or rosemary. Anything aromatic was of value: wood of aloes, amber, musk, or, for the less prosperous, cyprus, laurel and mastic. A typical recipe for a powder to throw on the fire{130} was one ounce each of choice storax, calamite and wood of aloes mixed in a mortar with rose-water of Damascus and made into small, oblong briquettes. The house was to be filled, whenever possible, with pleasant smelling plants and flowers and the floors sprinkled with vinegar and rose-water. If one was unfortunate enough to have to leave one’s house a prudent precaution would be to carry an amber or smelling apple. If amber was too expensive a cheaper but efficacious substitute could be contrived from equal portions of black pepper and red and white sandal, two portions of roses and a half portion of camphor. The resulting blend was then pounded for a week in a solution of rose-water and moulded into apples with paste of gum arabic.
It is doubtful if these precautions did anything to reduce the risk of infection with the possible exception of one recipe of Dionysius Colle for a powder, used for throwing on the fire, which contained sulphur, arsenic and antimony.{131} The first of these is now recognized as being destructive to bacteria as well as to rats and fleas. The other compounds, in most cases, had the minor merit of making the usually smelly medieval house a little more agreeable to live in.
Vegetable inactivity was the ideal posture in which to meet the plague. If one had to move, at least move slowly; exercise introduced more air into the body and, with the air, more poison. Hot baths, which opened pores in the skin, were to be shunned for the same reason, though it was beneficial to bathe the face and hands from time to time in vinegar or the inevitable rose-water.
There was general agreement also on the best kinds of preventive medicine. A fig or two with some rue and filberts taken before breakfast was a useful start to the day. Pills of aloes, myrrh and saffron were popular. One authority{132} placed his confidence in ten-year-old treacle blended with some sixty elements, including chopped-up snakes, and mixed with good wine. Rhubarb and spikenard was a compound easier to manufacture and to swallow. Witchcraft joined herbalism in the works of Gentile of Foligno{133} who recommended powdered emerald; a remedy so potent that, if a toad looked at it, its eyes would crack. Gentile also suggested etching on an amethyst the figure of a man bowing, girded with a serpent whose head he held in his right hand and whose tail in his left. To be fully operative the stone had first to be set in a gold ring.
Bleeding was generally held to be a useful preventive device; Ibn Khātimah,{134} for instance, feeling that it could only be beneficial to lose up to eight pounds. Diet was important. Anything which quickly went bad in hot weather was to be avoided. So was fish from the infected waters of the sea. Meat should be roast rather than boiled. Eggs were authorized if eaten with vinegar{135} but should never be taken hard-boiled.{136} Anyone trying to follow the advice of every expert would have been sadly perplexed. Ibn Khātimah approved of fresh fruit and vegetables but no one else agreed. Gentile of Foligno recommended lettuce, the Faculty of Medicine at Paris forbade it. Ibn Khātimah had faith in egg plant, another expert deplored its use.
It was bad to sleep by day or directly after meals. Gentile believed that it was best to keep steady the heat of the liver by sleeping first on the right side and then on the left. To sleep on one’s back was disastrous since this would cause a stream of superfluities to descend on the palate and nostrils. From thence these would flow back to the brain and submerge the memory.
Bad drove out bad and a school of thought maintained that to imbibe foul odours was a useful if not infallible protection. According to John Colle: ‘Attendants who take care of latrines and those who serve in hospitals and other malodorous places are nearly all to be considered immune.’ It was not unknown for apprehensive citizens of a plague-struck city to spend hours each day crouched over a latrine absorbing with relish the foetid smells.
A tranquil mind was one of the surer armours against infection. Ideally one should retreat to Boccaccio’s enchanted glade, live beautifully, pass one’s time in dalliance and in practising the art of conversation. But dalliance should not be carried too far: sex, like wrath, heated the members and disturbed the equilibrium. One’s mind should be resolutely closed to the agonies of one’s fellow men; sadness cooled the body, dulled the intelligence and deadened the spirit.
It seems unlikely that the intelligent and enlightened men who worked out these preventive measures had any great faith in their efficacy. Essentially they were a morale-building exercise: the morale of the physician, in that they made him feel at least remotely in control of the situation, and of the patient, in
that they offered a slight hope of escape from death. But if the doctors lacked confidence in their capacity to keep the plague at bay, still more did they doubt their ability to cure it once it had struck. They knew too well how few of the sick recovered. But this knowledge of their helplessness did not stop them putting forward a host of remedies.
Bleeding was an even more important part of the cure than it had been of prevention. The blood that emerged from the infected would normally be thick and black; it boded even worse for the victim if a thin green scum rose to the surface. If the patient fainted, instructed Ibn Khātimah somewhat heartlessly, pour cold water over him and continue as before. Most surgeons bled for the sake of bleeding, not worrying much where the incision was made. John of Burgundy{137} was more scientific. He believed in the existence of emunctories, from which the poison could be expelled by bleeding. The evil vapours, having entered by the pores of the skin, were carried by the blood either to the heart, the liver or the brain. ‘Thus, when the heart is attacked, we may be sure that the poison will fly to the emunctory of the heart, which is the armpit. But if it finds no outlet there it is driven to seek the liver, which again sends it to its own emunctory in the groin. If thwarted there, the poison will next seek the brain, when it will be driven either under the ears or to the throat.’ Each emunctory had a surface vein which corresponded to it and a skilled surgeon could there intercept the poison on its devil’s progress around the body and draw it off before it did more mischief. A common and disastrous mistake was to make the incision on the wrong side of the body; this not only wasted good blood but meant that healthy limbs were corrupted by the degraded liquid which poured in to make up the loss.
The Black Death Page 8