The Greatest Benefit to Mankind: A Medical History of Humanity

Dietetics, by contrast, was the main therapeutic recourse of the physician regulating lifestyle in accordance with the six non-naturals. Spurred by the revival of international commerce, pharmacy also developed, especially in Venice, where drugs imported from the East were traded in large stores (apothecai), which came to mean a druggist’s shop.

Relations between physicians and surgeons were not always plain-sailing, especially with eminent surgeons like Henri de Mondeville, Guy de Chauliac and John of Arderne (c. 1307–70) laying claim to learning as well as a good eye, a steady hand and a sharp blade. According to de Mondeville, ‘it is impossible to be a good surgeon if one is not familiar with the foundations and general rules of medicine [and] it is impossible for anyone to be a good physician who is absolutely ignorant of the art of surgery.’

Among the famous early surgical writers was Lanfranc of Milan (c. 1250–1306). Italian by birth, he settled in Paris where he wrote his Chirurgia magna, an expansion of his more popular Chirurgia parva. They were both translated into French, Italian, Spanish, German, English, Dutch and Hebrew. The Grand Surgery is divided into sections on general principles, and on anatomy, embryology, ulcers, fistulas, fractures and luxations, baldness and skin diseases, phlebotomy and scarification, cautery and diseases of various organs. There is also a lengthy section on herbs and pharmacy. Lanfranc was valued by his distinguished successors, de Mondeville and de Chauliac.

Henri de Mondeville (c. 1260-f. 1320) was born in Normandy, studying at Montpellier, Paris and Bologna. Travelling widely, he spent some time as a military surgeon to the French royal family, and lectured in surgery and anatomy at Montpellier and Paris. He planned his Cyrurgia (begun in 1306 but never completed) along traditional lines, opening with anatomy and moving on to wounds. Attention was paid to the contentious topic of wound treatment. Mondeville advocated simple bathing of wounds and immediate closure, followed by dry dressings with minimal loss of flesh or skin. His preference was for dry healing without pus formation, a view contradicting Hippocratic wisdom but already advocated by Hugo of Lucca (c. 1160–1257) and his disciple, Theoderic (1205–96), who had boldly maintained in his Chirurgia (1267) that ‘it is not necessary that pus be formed in wounds’.

This new approach met opposition from supporters of conventional wound salves: plasters and powders designed to promote suppuration; since Greek times it had been taught that certain types of pus (known as ‘laudable pus’) were beneficial, conveying poisoned blood out of the body. The Salernitan school had thus recommended keeping wounds open to allow for suppuration and healing per intentio secundam (by second intention), from the base of the wound up.

The most prominent surgeon of the next generation was Guy de Chauliac (1298–1368), educated at Montpellier and Bologna. His great work, the Chirurgia magna, was fully comprehensive, covering anatomy, inflammation, wounds, ulcers, fractures, dislocations and miscellaneous diseases belonging to surgery. An astonishing exercise in surgical erudition, it contains no fewer than 3299 references to other works, including 890 quotations from Galen. This parade of sources was calculated, since Chauliac was concerned to show surgery to be a learned art:

The conditions necessary for the surgeon are four: first, he should be learned, second, he should be expert: third, he must be ingenious, and fourth, he should be able to adapt himself. It is required for the first that the surgeon should know not only the principles of surgery, but also those of medicine in theory and practice.

Chauliac’s Chirurgia was translated into several languages. In the pus bonum et laudibile debate, he did not exactly take sides, though he appears to have been hostile to traditional wound salves, judging they did more harm than good. The work also contains fascinating details about his own times, including first-hand reports of the Black Death, descriptions of surgical instruments and operations, and his often damning judgments on his contemporaries. Like most medieval practitioners, he offered a pot-pourri of Hippocratic treatments and ones of a magico-religious flavour. Epileptics, for instance, were to write in their own blood on a piece of parchment the names of the Three Wise Men, and to recite three Pater Nosters and three Ave Marias daily for three months.

The most distinguished English surgeon was John of Arderne, who served under John of Gaunt in the Hundred Years War and produced a Treatment of Anal Fistulas. For this operation, his technique was to place the patient in the lithotomy position. Four ligatures were taken up through the fistula, and their ends, drawn down through the anus, were knotted to stop the bleeding. Next, he pushed one grooved instrument through the fistula into the rectum, where it made contact with another. He then made a bold cut with his scalpel to remove the whole intervening segment, and stopped the bleeding between the ligatures with a hot sponge. The wound was cared for by cleaning and the patient was given daily enemas.

MEDICINE AND THE PEOPLE

From the twelfth century, Europe blossomed: population rose, trade boomed, and courts and cities acquired a new sophistication. Such circumstances helped medicine. Though learned physicians were at the top of the tree, they constituted only a small fraction of all those offering medical services, and larger towns attracted a diversity of healers. Around 1400 Florence boasted not only graduates of Padua and Bologna, but bone-setters from Rome and families specializing in eye-diseases, hernia and the stone. Herbalists, midwives and pedlars of folk remedies thrived, and parish priests plied pious cures.

With numbers rising, medicine needed to organize itself. This happened first in urban Italy, where medical guilds assumed responsibilities for apprenticeship, examination of candidates, location of pharmacists and supervision of drugs, food and herbs. As early as 1236 Florentine physicians and pharmacists grouped into a single guild, recognized as one of the city’s seven major crafts.

Medical organization took various forms. In southern Europe there was no great gulf between surgeon and physician: surgery was a desirable skill for a physician to acquire. In Frederick II’s regulations for the Kingdom of Sicily (c. 12 31), a licence to practice medicine could be gained only after five years of study which included surgery, and in Italy the chance to learn surgery at university helped to prevent professional rancour between the two branches. Elsewhere the gap widened, however, for beyond Italy surgery was excluded from the academic curriculum. In northern Europe surgical training and practice were organized on a guild basis, through apprenticeship, and so were regarded by physicians as infra dig.

In Paris, the surgeons’ organization began in 1210 when the College of St Cosme (Côme or Cosmas) was established. Its members were divided into the long- and the short-robed, only the former being entitled to operate. Training was mainly practical and the college granted three degrees: a bachelor’s, a licence and a master’s. A three-cornered tussle developed between physicians of the faculty, the surgeons of the college, and the barbers, who did bleeding and the like. The introduction of anatomy added to the confusion, for dissections were under the direction of a physician but the knife-work was performed by a surgeon. Not till 1516 was the conflict resolved, with the surgeons ceding precedence to the physicians, for both could unite in antipathy towards the ‘ignorant’ barbers. In the German states and England, the barber-surgeon became typical, but in Italy, Spain and southern France, that hybrid occupation never gained prominence.

In London, the Fellowship of Surgeons came into being in 1368–9, and a Company of Barbers was chartered in 1376. The tiny band of university-trained physicians did not organize themselves until 1423, when a group led by the cleric and court physician, Gilbert Kymer (c. 1385–1463) petitioned for a joint college ‘for the better education and control of physicians and surgeons practising in the city’. Not until the founding of the College of Physicians of London in 1518 could the physicians regulate metropolitan practice. Though intra-professional conflicts flared, they were not universal. In small cities like Bristol or Norwich, physicians, surgeons and barbers found strength in unity. And, in any event, professional tussles in the late medieval centuries reflect the surging number of healers and their dawning sense of civic standing.

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.