April 1, 2010 12:46:00 PM
The Black Death struck Europe in the 14th century, killing hundreds of millions of people. There was little understanding of even the most basic causes and effects that might have been involved in the spread of the disease. It is not true, however, that the scientific insights about disease that were to start in the Enlightenment and continue to our own times represented the first understanding of the plague as something other than a magical curse or a lesson from God. In Italy, the plague recurred in an epidemic from 1575 to 1578, and during this particular outbreak, people began some primitive but essential epidemiology and even societal treatment.
This is the surprising lesson of Cultures of Plague: Medical Thinking at the End of the Renaissance (Oxford University Press) by Samuel K. Cohn Jr., an astonishingly detailed look at the beginnings of an intellectual revolution. The author, a specialist in the Italian Renaissance and in the history of disease, reminds us that there was "no simple binary progression from a supposed premodern to modern medical thought." The doctors, medical workers, and even gatekeepers in the middle of the plague in Milan, Padua, and Venice observed, looked at the illness in new ways, and wrote about what they saw.
The writings are essential to Cohn''s study, and represent a basic shift in the way the plague was documented. Included here are graphs that show by year the number of Italian tracts, broadsheets, and other imprints about the plague; there is an unmistakable spike around 1576, and no such dramatic increase in similar graphs from French- and German-speaking regions. The writings before this time, written always by university-trained doctors, concentrated on the classic ancient understanding of disease. Galen, Hippocrates, and Arab authorities were cited, and explanations were based on the theory of humors, the configuration of stars and planets, and of course the doings of God or of Satan.
The rush of tracts for this particular epidemic represented a change. Barber-surgeons might write about the plague, and drug-sellers, merchants, lawyers, artisans, clerics, and minor officials all got into the act, a printed resource which Cohn has mined as the bibliographical backbone of his book, "a wide spectrum of authors from cardinals to cobblers, in prose and verse." The tracts from this time were not just in academic Latin but in the vernacular. That there was a broader
participation by non-doctors partially explains why the plague was this time examined in a new way, but at least some of the doctors were looking at disease anew, too.
Many of the doctors continued to analyze and explain the disease in the same way they had done for centuries, concentrating on signs and symptoms of illness that befell the individual, and proposing individual treatments. Some of these treatments, like bleeding, were quackery, but doctors also recommended sensible practices like handwashing, covering one''s mouth and nose with a sponge or bread soaked in vinegar when near infected people, and using smoke and scents as disinfectants.
Doctors seemed (to themselves) to be making a difference with such steps, although it must be said that whatever disease they were seeing, it was not the virulent type of Black Death of a couple of centuries before. Doctors'' tracts at that time despaired of understanding or treating the illness, urging the only recourse available, praying to God. Now doctors had a new confidence, and it was gained in part by disregarding ancient teachings. Galen, for instance, had barely a notion of transmission of disease by goods or persons.
The doctors of the plague that is the subject of this book may have used Galen and other ancients as an initial framework for understanding the disease, and they used plenty of Greek and Latin in describing buboes and other symptoms, but they did more. Lists of symptoms were made not just from what the ancients would have predicted, nor from authors about plagues in the centuries before, but from direct observation. Experience and even experimentation began to be stressed; following abstract ancient theories was not going to give the understanding that these doctors made. It seems like a small step, but doctors began documenting that mortality was occurring within households, getting an idea of the concept of contagion and disease transmitted from one person to another rather than being "miasmic," transmitted by air that was somehow bad.
The plague tracts also documented an understanding that the illness, while not limited to afflicting the poor, did so disproportionately. Galen had insisted that a true plague would cut down the privileged; one author had written during the original Black Plague that "the planets looked down on rich and poor alike." In the recurrence Cohn writes about, however, even granted that the elite left their stricken cities, it was recognized that the poor endured the most mortality. There were attempts to explain why this should be so. One author wrote that plague struck the lower classes because they were "forced to eat bad and corrupt food, stinky bread, grass, and unknown roots". The poor could not count upon clean water; polluted water began to be recognized as a cause of disease. The poor lived in filth; there was lack of plumbing in their houses, buckets of excrement were kept under the beds, the windows (if any) were sealed, and dirt accumulated. Seeing the social effects of the plague in this new way resulted in new ways of treatment.
"To judge from their published treatises," writes Cohn, "the crisis of 1575 fundamentally altered doctors'' approach to and thinking about plagues from the individual patient to the community."
The causes of plague were social, so the solutions had to be political. Recommendations were made about how the cities ought to issue decrees about administering the sick, building new hospitals, enacting quarantines, cleaning the streets, executing those who dealt in infected goods, and other public measures. At least some of these decrees were put into action, and in addition, charity to improve the lot of the poor was enforced. There was a place for religious processions and other ceremonies, but secular governments were in charge of making practical changes. The point of view developed in this outbreak attributed any triumph over disease to rulers and civil servants, the subjects of many subsequent literary celebrations.
Of cours,e the doctors and citizens had no real knowledge of the disease roles of rats, fleas and Yersinia pestis, but the capacity to look at clinical evidence without the burden of forcing it into ancient medical theories did enable some important changes, and was a foundation for better understanding as the centuries went on. Cohn, in an erudite and beautifully organized book, has cited a multitude of tracts, and quoted many of them here to show the beginnings of these initial ideas about how governments should involve themselves in the administration of health procedures for their citizens. Four centuries later, we are still trying to answer the same question for our own times.
Rob Hardy is a local psychiatrist who reviews books for a hobby. His e-mail address is firstname.lastname@example.org.