Читать книгу The Greatest Benefit to Mankind: A Medical History of Humanity - Roy Porter - Страница 41

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.