The Great Pox: The French Disease in Renaissance Europe.

Jon Arrizabalaga, John Henderson, and Roger French. New Haven and London: Yale University Press, 1997. xv + 352 pp. illus. $35. ISBN: 0-300-06934-0.

The pandemic that descended upon western Europe in 1347 and continued virtually unbroken through the end of the seventeenth century has generated an enormous historical literature. Plagues were a constant presence in the lives of medieval and early modern people, causing fear, terror, and social disruption. Jean-Noel Biraben, in his monumental Les hommes et la peste en France et dans les pays europeens et mediterraneens (1975-1976), concluded that plague struck somewhere in Europe during every year, save only two, between 1347 and 1670.

What exactly was the agent that caused the Black Death and the succeeding epidemics of the late medieval and early modern periods? Most historians agree that the Black Death was a massive epidemic of bubonic plague, a disease of rats caused by the bacillus Yersinia pestis. When transmitted to humans by fleas, the organism spreads, causing the blackened tissue and necrotic pustules classically associated with the disease and which gave rise to the medieval epidemic's name.

But the classical explanation is not without its problems. Many of the symptoms of the disease described by contemporaries, especially during epidemics of the sixteenth and seventeenth centuries, are strikingly inconsistent with those of bubonic plague. One of the most difficult problems to reconcile with the classic model of bubonic plague is the absence of rats in the contemporary accounts of the epidemics. Given the massive human mortality, deaths of millions of rats should have preceded outbreaks of the plague. Yet the historical record is strangely silent about rats. Nor can the rapid speed with which the plague spread be easily reconciled with the rather sedentary habits of the house rat. In order to explain this inconsistency, Biraben favored a model for the pandemics of preindustrial Europe based upon interhuman spread of bubonic plague via the human flea, as opposed to the rat flea model advocated by English historians such as J. F. D. Shrewsbury (A History of Bubonic Plague in the British Isles, 1970). While the French model solved some problems, it raised others, as it failed to account for certain demographic and seasonal aspects of the pandemic. Moreover, contemporary descriptions of the disease's symptoms yield conflicting interpretations: some seem consistent with bubonic plague, while others seem incongruous or inconclusive.

In his short, sweeping essay on the Black Death, the late David Herlihy engages with these issues in a fresh and original way. The Black Death and the Transformation of the West consists of three lectures that Herlihy delivered in 1985, to which Samuel K. Cohn, Jr. has added extensive notes and an introduction that assesses the lectures in the context of Herlihy's oeuvre. Instead of accepting the prevailing view of the epidemic, Herlihy finds clues to the puzzle in a source hitherto untapped by historians: the acts and processes used to judge candidates for sainthood, later collected in abbreviated form in the Acta Sanctorum. Some saints, such as the obscure Rose of Viterbo (d. 1252) were looked upon as spiritual protectors from the plague. Rose was rediscovered during the epidemic that struck Viterbo in 1450; and in gratitude for her help, the local government pressured the pope to initiate canonization procedures. During the process that followed, many citizens came forward to testify concerning cures from the plague.

Although some of the depositions mention buboes, the lymph node swellings characteristic of (but not unique to) bubonic plague, the most common "signs of the plague" were lenticulae (freckles) or pestilentialis punturae (pestilential points) - in other words, darkish points or pustules covering large areas of the body. Such symptoms are not characteristic of bubonic plague, but are common to a number of other diseases such as anthrax and typhus. For these reasons, Herlihy follows the English epidemiologist Graham Twigg in concluding that it was unlikely that bubonic plague was the agent of the Black Death. Twigg tentatively suggested anthrax as the cause of the infection, a hypothesis that Herlihy neither confirms nor refutes. (In a footnote, Cohn offers an even stronger endorsement of Twigg's negative, but almost completely ignored, findings.)

Whatever the infectious agent of the plague might have been, it along with persistent famine and civil disruption - may have killed off as many as two-thirds of the population of Europe by 1420. In some cities in Italy and England, the population was reduced by as much as eighty percent. In his introduction, Cohn points out that these lectures represented for Herlihy a reversal in his thinking about the demographic changes of the late Middle Ages. In his early work, Herlihy had argued that social, political, and economic circumstances formed the crucible from which the plague of the mid-fourteenth century emerged. By 1985, however, he no longer saw Europe as heading inexorably toward a Malthusian reckoning, but instead saw Europe caught in a "deadlock": "a demographic and economic situation which paralyzed its capacity to improve the ways it produced its goods." But for the Black Death, that situation might have persisted indefinitely, Herlihy argues. "The plague broke the deadlock, and allowed Europeans to rebuild their demographic and economic systems in ways more admissive of further development" (81).

Although the plague caused tremendous short-term disruption in the economic life of Europe, in the long run the breaking of the Malthusian deadlock freed resources. Land could be used for purposes other than cultivating grain, while mills could be enlisted for new industrial purposes. As a result, the late Middle Ages was a period of impressive technological innovation. Europeans, even as their numbers decreased, were living better.

Because high mortalities cut short the careers of priests, lawyers, craftsmen, and other professionals, the immediate post-plague period was "an age of new men" (45). Society needed certain services, and in such times of crisis it had to allow even unlicensed or poorly trained people to perform them. Guilds were forced to reach out beyond traditional cadres. Lay persons were called upon to perform the roles traditionally reserved for priests; thus the Black Death stimulated the growth of lay religious movements. The deaths of great numbers of wealthy persons led to a plethora of new bequests, many of which went to the foundation of new colleges and universities (Cambridge University acquired four new colleges between 1348 and 1362). Herlihy speculates that the growth of new national universities undercut the dominance of the old centers of learning, notably Paris and Bologna, and "freed the curriculum of the weight of traditional subjects" (70). The decline in the number of teachers who were proficient in Latin may, in turn, have stimulated the growth of the vernaculars as languages of instruction, at least at the level below the universities. But the bad quality of university Latin also provoked a counter-movement: an effort to restore the language to its classical purity. Thus the Black Death may have given birth to Renaissance humanism. Whatever the merits of these conjectures, Herlihy's provocative essay will doubtless raise new questions and challenges for future historians.

If the identification of the Black Death as bubonic plague is problematic, that model is even more difficult to reconcile with the epidemics of the early modern period, when the matter is further complicated by the appearance of new diseases such as typhus and influenza. The physician and medical historian Ann Carmichael, in Plague and the Poor in Renaissance Florence (1986), has argued that the epidemics that hit Florence in the fifteenth century were actually bubonic plague mixed with other diseases. Guided in part by this insight, A. Lynn Martin turns to a hitherto completely neglected source for the history of disease - the letters of Jesuit missionaries to their superiors - and finds that in the letters that contain descriptions of epidemics (about 1,500 in all) any sort of retrospective diagnosis is extremely problematic. Although buboes are frequently mentioned, petechia was also a common symptom. Moreover, Jesuit accounts do not mention rats. If the Jesuits encountered bubonic plague, the disease clearly did not act according to modern medical observations it. For these reasons, Martin prefers to talk not of "plague," but of "pest," the ambiguous term employed by contemporaries. Hence also the title of his book: Plague? Jesuit Accounts of Epidemic Diseases in the 16th Century.

What did early modern Europeans mean by "pest"? Jesuit descriptions reveal that the four primary characteristics of the disease were its contagious nature, high mortality, quickness of death, and the appearance of the bubo. Although the sources do not contribute anything new to the medical history of the plague, the rich descriptions and graphic accounts of epidemics found in the letters (many of which Martin quotes in extenso) add a human element lacking in most medical histories.

In general, Martin lets the Jesuit sources speak for themselves, although on one point he finds it necessary to come to the defense of the order. When the plague struck Milan in 1576-1577, the cardinal archbishop Carlo Borromeo attacked the Jesuits for fleeing from the epidemic rather than remaining to care for the sick and dying. The Capuchins, by contrast, served the pest-stricken in the lazzaretto (or pest house, where plague victims were confined), and suffered numerous losses. Even if the Jesuit record did not match the "reckless disregard" of the Capuchins, Martin argues, their more prudent approach of leaving behind only a few of their brethren to care for the sick enabled the order both to survive and to serve plague victims.

Although the Jesuits held fast to a providential view of the plague, viewing the pestilence as the just punishment of an angry God, Martin's sources reveal that they took a surprisingly optimistic view of divine providence. An angry God could also be a merciful God, and thus He supplied humanity with secondary remedies to cure their physical ailments. In contrast to the fatalism characteristic of Protestant reactions to epidemics, the Jesuits maintained their faith in the medical profession and its remedies.

When the plague broke out in Milan again in 1630, Borromeo's nephew, Cardinal Federico Borromeo, was the city's archbishop. Federico was, among other things, an avid collector of books, and his great library became the core of the Biblioteca Ambrosiana, arguably the first public library of Renaissance Italy. Federico's Latin memoir of the plague of 1630 in the Ambrosiana Library, now edited by Armando Torno and translated into Italian by Ilaria Solari (La peste di Milano del 1630), vividly describes the fear and paranoia that accompanied plague epidemics. Besides reporting popular reactions to the contagion, the memoir chronicles the central drama of Alessandro Manzoni's version of the epidemic in I Promessi sposi: the popular belief that untori, or plague anointers, were responsible for spreading the disease by means of unguents which they wiped on houses, city walls, and church pews. Indeed, Manzoni mentioned the cardinal's unpublished memoir as one of the principal sources for his account of this aspect of the plague.

Although Borromeo was on the whole skeptical of the more outlandish reports of untori, he thought some of the accounts to be credible, including stories that certain anointers wiped prayer books with unguents in order to spread plague among the clergy, while others had contaminated fruits and vegetables in the marketplaces. Accounts of untori making pacts with demons in exchange for plague unguents, evidently widespread, suggest a plague-stricken city in which disorder and panic were almost as threatening as the epidemic itself. As for the agent of the infection, Borromeo drops an intriguing clue. Although the cardinal does not mention rats in the memoir, he reports that the disease infected cattle "with extreme violence," suggesting anthrax as a possible cause of the epidemic.

Also collected in the volume are a number of related documents concerning measures used to combat the epidemic, including Federico's instructions to the clergy concerning visitations to the sick and dying. The Cardinal testified that medicinal remedies against the plague were completely useless. Contempory medical theory held that the plague was contagious; hence the main public measure against it was quarantine of victims in lazzaretti. In order to effect such extreme social control measures, city governments instituted public health boards, empowering them to deal with the emergency.

In Venice, that office was called the Provveditori alia Sanita, which was created by the Senate in 1485, initially to recommend public health measures during times of plague epidemics. In I Mali e i rimedi della Serenissima, Nelli-Elena Vanzan Marchini documents how, under threats of successive epidemics of plague and the appearance of new diseases such as typhus and syphilis, the office's power was gradually expanded to include not only the regulation and licensing of medical practice but also broad social control in matters such as hygiene, poverty, vagrancy, and (with the appearance of syphilis) prostitution. One of the most persistent motifs of the plague years was the ancient belief that disease was something brought into the community from the outside, or by marginal elements from within, i.e., by foreigners, vagrants, beggars, prostitutes, or Jews.

The association of the poor with the plague may have had an epidemiological basis. As Ann Carmichael has persuasively argued, many of the "plagues" of the early modern period were probably concurrent epidemics of bubonic plague and other infectious diseases. The epidemic that struck northern Italy in the late 1520s was almost certainly typhus, although bubonic plague may have been present in some locales as well. Typhus is principally a disease of poverty; it targeted poor, overcrowded, and malnourished urban populations. But this can only be part of the explanation for official responses to epidemics. Although she does not marshall convincing archival evidence to prove it, Vanzan Marchini argues that the Venetian experience is consistent with Carmichael's central thesis that plague legislation derived more from contemporary social beliefs about poverty and vagrancy than from experience with the disease.

The public health offices gained extensive powers in many northern Italian cities. In Naples, by contrast, the management of public health was quite haphazard until the mid-seventeenth century. It was not until the arrival of the plague in 1656 that the government was finally forced to create the Magistrato della Sanita, and even that office proved to be rather ineffectual. Public health continued to be a matter for local communities and neighborhoods. David Gentilcore's Healers and Healing in Early Modern Italy is a welcome addition to the literature on early modern medicine precisely because of its focus on the Kingdom of Naples. Whether due to modern prejudice against the "backward" Mezzogiorno or because of the ravages that the Neapolitan archives suffered during the Second World War, southern Italy has been largely neglected by medical historians. This excellent book will go far toward bringing that region back into the picture of early modern medicine.

The principal medical tribunal in the kingdom of Naples, the Royal Protomedicato, was broadly fashioned on the Spanish model. Its responsibilities included the inspection of pharmacies, overseeing the selection of town physicians, and licensing practitioners. It never evolved into the system of medical police that developed in Venice and Milan. And yet, while public health practices in Naples were quite distinct from those in northern Italy, Gentilcore argues that in terms of the variety of its medical practitioners, the kingdom of Naples was typical of early modern Italy as a whole. Gentilcore sees three interacting spheres of healing during the early modern period: medical, ecclesiastical, and popular. While the three healing cultures interpreted disease in different ways, they overlapped and competed with one another. Naples's medical pluralism embraced not only physicians, surgeons, apothecaries, and midwives, but also herbalists, priests, miracle-workers, and a great variety of charlatans and unorthodox healers, such as the sanpaolari, or snakehandlers who sold antidotes against poison.

Why were charlatans and other unorthodox healers so popular when, manifestly, their cures were based upon erroneous physiological and pharmaceutical assumptions? One reason, Gentilcore argues, was that "they mixed care for the body with an understanding of popular culture and sensibilities" (118). The cures they offered were consistent with popular culture's understanding of disease as a poison to be expelled, or as something that assaults the body from the outside. In finding a place for the irregular as well as the regular healers in the medical world of early modern Italy, Gentilcore has produced an important work that will, one hopes, be a model for similar studies.

Perhaps no subject better illustrates the dangers of historical mistranslation - the temptation to identify historical diseases with supposed modern pathogens - than outbreaks of"new" diseases such as mal francese. Jon Arrizabalaga, John Henderson, and Roger French, the coauthors of The Great Pox: The French Disease in Renaissance Europe, make it clear at the outset that their book "is not a history of syphilis" (1). It is, rather, a reconstruction of contemporary understandings of the malady known as the French Disease before it became syphilis. This distinction is crucial to the kind of constructivist medical history they propose to write. Instead of seeking to identify the timeless "essence" of the disease, they focus upon the historical circumstances in which knowledge of the illness was built up. This approach leads them much farther afield than traditional histories of medicine. In addition to examining formal medical treatises, they investigate hospital care of mal franciosati (pox victims), the reactions in the courts, the competition among empirics and physicians, and the academic debate over whether mal francese was a new disease or one known to the ancients.

In April 1497, several scholars met at the court of duke Ercole d'Este in Ferrara to debate the French Disease. The duke had a personal interest in the subject, since several members of his family, including his heir, were infected with the pox. The participants in the debate included a court physician, a professor of medicine at the studio of Ferrara, and the renowned humanist Nicolo Leoniceno. The earliest major academic debate on mal francese, the disputation at Ferrara underscored the main academic positions on the origins, nature, and cure of the disease. As befitted academics of the day, there was much concern over finding the proper Latin name for the disease. The authors point out that the variety of vernacular names for the illness - the French Disease, the Neapolitan disease, grosse verole, mal de siment, the curial disease (because it "followed the court") - in effect resigned the contagion to vernacular healers. "The French Disease had to have a Latin name so that the physicians could draw it into the apparatus that distinguished them from other groups and justified their claim to superiority" (118).

Among the points brought out by the debate at Ferrara was the reluctance of academic physicians to acknowledge that the French Disease, or for that matter any disease, was unknown to the ancients. For to admit the possibility of new diseases was to call into question the authority of academic medicine. Although the disputants at the court of Ferrara could not agree among themselves which ancient disease mal francese was to be identified with, none dared to assert that the contagion was truly novel.

This was not so for empirics and charlatans, who had everything to gain from the fear and paranoia that new diseases inevitably brought in their wake - mal francese not excepted. The failure of traditional medicines that physicians used to treat the infection made it an excellent target for medical "secrets" rended by empirics. The authors of The Great Pox point out that a new medical market for cures arose around those afflicted with the French Disease. Patients were growing impatient with the physicians' strict regimens; they wanted a quick dose for what ailed them. Empirics delivered with an arsenal of "specifics" that promised fast results. The authors suggest that this represented a radical departure from the healing strategies used by orthodox physicians. The empirics "claimed that their medicines were specific to the disease rather than to the patient" (253). Whether or not the appearance of mal francese can be considered a turning point in the shift towards a more "ontological" conception of disease is not yet clear; but it is interesting to note that physicians, instead of rejecting empirical cures outright, opted instead to appropriate and "medicalize" them. As the Bologna medical professor Giovanni Zecchi explained, remedies discovered by empirics were not safe unless "corrected and handled by a particular method" (256).

Two meticulously researched and tightly constructed chapters of The Great Pox tell the story of the origins and development of the hospitals for the incurables (as the hospitals for mal francese sufferers were called) in Italy. Originally founded by charitable confraternities, these institutions eventually became fixtures of virtually every major Italian city. Although there were doubtless genuine Christian motives behind the movement to found Incurabili hospitals, the authors also point out that the appearance of the mal franciosati on the streets of Italy's major cities made the municipal authorities nervous. To them, it was the sick poor who were creating the problem. Just as during epidemics of the plague, it was convenient to find a scapegoat for the contagion.

The archival record is particularly rich for the hospital at San Giacomo in Rome. John Henderson (who was responsible for this section of the book) makes particularly creative use of this material, which includes, uniquely among Incurabili hospitals, patient registers from the second half of the sixteenth century. Two important findings emerge from the registers: (a) there was a strong connection between disease and poverty, and (b) the poor received radically different treatment than the rich. Thus there was a relatively high incidence of well-to-do patients among the hospital's clientele in the years when guaiacum (or Holy Wood, widely regarded as a panacea for mal francese) was administered. The very poor, by contrast, tended to dominate during the years when Holy Wood was not administered. Although this book suffers from some of the problems of inconsistency of style and strategy that inevitably afflict multi-authored books, the work stands out as a fundamental contribution to the history of early modern epidemics and a model of how the history of disease ought to be written.

Gianna Pomata's Contracting a Cure is another excellent example of what can result when a skilled historian encounters a rich archive. The subject of her important book is the fundamental shift in the relationship between healers and patients in early modern Bologna. Using the records of the Protomedicato in the Bologna state archive, she explores the tradition of "agreements for a cure" whereby healers were contractually bound by an agreement with a sick person specifying that the practitioner would heal the patient within a certain prescribed period of time. Only if the patient recovered from the illness would the medical practitioner be paid. Moreover, strange as it may seem, the healing was to be determined solely by the patient's perception.

It goes without saying that this system of justice and medical ethics was radically different from our own. As Pomata somewhat wryly puts it, "What was once a social reality is now the wildest of all medical utopias" (169). Such contracts, she argues, implied a "horizontal" model of healing in which the healer and the patient stood on equal ground. Patients' rights were protected by the notion of a moral economy of medicine in which healers' expertise was measured against the common-sense yardstick of the patient's sense of well-being.

This system, however, was actually quite fragile. It was fundamentally at odds with the professional interests of the medical community. In describing the medical system as seen by the doctors versus that seen by the sick, Pomata draws a number of contrasts. The doctors were mainly concerned with preserving a hierarchical system that kept lower order practitioners subservient to them. They insisted upon their role as protectors of the sick and guardians against the dangers of illicit (i.e., unlicensed) practitioners. To the people, on the other hand, the cure agreements functioned as a safeguard against ineffective practice. Moreover, in popular culture health consisted of maintaining a proper "flow" of bodily fluids (hence the predominance in popular medicine of cures that evacuated ill humours). In learned medicine, by contrast, therapy was associated with the exercise of authority over the body by means of diet and regimen, a "rule of living" that had to be obeyed.

Pomata traces how the horizontal model of healing gradually eroded, and finally broke down altogether, under the weight of the growing professionalization of the medical community. The cure agreements were a major obstacle to professionalization. Indeed, they violated two basic tenets of medical professionalism: first, that medical practitioners deserve to be paid because they are licensed members of the profession, and second, that payment does not depend on the patient's satisfaction. "As medical ethics became increasingly shaped by the principles of professionalism, negotiating with patients was rejected by physicians as demeaning and unprofessional" (46). In uncovering this lost system of medical healing, Pomata has not only enriched our understanding of early modern medical practices, but has provided essential tools for a critical examination of our own.

From the standpoint of the issues raised by other books in this review essay, Winfried Schleiner's Medical Ethics in the Renaissance is rather disappointing. The book does not touch on any of the themes that seem to have characterized the ethics of medical practice: fair price, patients' rights, the obligation of the healer to heal, and so on. Nor does it deal with the theme of professionalization and its impact upon medical ethics. Instead, it is a rather selective examination of several concerns in the academic literature of the period, for example, whether it is ethical to lie to a patient in the interests of health (the placebo problem); whether spilling male seed is moral, even if beneficial to health; and whether protecting oneself against syphilis promotes sexual license. Such questions, though not without interest, seem a bit marginal to the issues one would normally consider as falling within the domain of practical medical ethics. With its many digressions, sidetracks, and parenthetical comments, this exasperating book seems to have a hard time sticking to its subject.

Several conclusions may be drawn from these recent works on epidemics and medical practice. First of all, it is clear that much work remains to be done before we can identify with any degree of certainty what biological agents were responsible for the medieval and early modern epidemics. As several of the books under review suggest, contemporary accounts are often ambiguous and difficult to decipher. Moreover, as we know from our own experience of the AIDS epidemic, new diseases can emerge apparently without precedent, and perhaps can just as mysteriously disappear. It is entirely possible that the agent of the Black Death no longer exists.

Yet the task of understanding what caused the late-medieval and early modern plague epidemics may not be as hopeless as it seems. Recently a group of French scientists published evidence from DNA samples taken from the dental pulp of skeletons excavated from a late-sixteenth century mass grave in Provence known to contain plague victims. The analysis showed that the DNA taken from the skeletons matched that of the modern plague bacillus (Proceedings of the National Academy of Sciences 95 [1998]: 12637-12640). Thus the evidence is strong that late-sixteenth century plague victims were infected with Yersinia pestis. If such techniques could be applied to the fourteenth century, we might be in a better position to understand what caused the Black Death.

How far such evidence would take us toward a real historical understanding of early epidemics is another matter. Even if we were able to identify medieval and early modern diseases in modern medical terms, that alone would not "explain" them. As these studies suggest, the experience of disease is conditioned as much by cultural as by biological factors. In my view, as historians we must continue to make contemporary perspectives on disease our main concern, a point eloquently reinforced by Arrizabalaga, Henderson, and French in The Great Pox. Understanding what shaped those perceptions, and how such understandings influenced responses to disease, should be our principal explanatory goals.

These works go a long way toward achieving these aims, not only in suggesting themes for further research but also in offering novel methodological approaches. As suggested by Gianna Pomata and David Gentilcore, early modern understandings of disease were conditioned by class, gender, religion, and professional status. Naturalistic, religious, and magical views of illnesses and their treatment coexisted, although not always without tension. Thus, Gentilcore's emphasis upon medical pluralism in early modern Italy has wide and important implications for the study of early modern healing. Similarly, A. Lynn Martin's strategy of problematizing the identity of the plague and insisting upon using the ambiguous label "pest" forces us to come to terms with contemporary perspectives on the "plague" epidemics.

Pomata notes that traditional histories of medicine have taught us much about the relationship between doctors and illnesses, but very little about the relationship between doctors and patients, and her book suggests an important reason why this is so. The deficiency, she suggests, is probably due to the distinctive character that the doctor-patient relationship assumed during the course of medical professionalization, namely that it was subordinated to the one between the physician and the abstract entity "illness." These implications of medical professionalism need further development, as do related themes such as how competition and the marketplace influenced perceptions of illness and healing. Did the thriving trade in medical "secrets" influence the development of the conception of disease as a distinct ontological entity? Contemporary understandings of mal francese raise still another question: how did diseases function as social metaphors? Do diseases help frame debates about society and social policy? We need to know more about the individual experience of disease in the Renaissance, about the influence of culture on conceptions of disease, and about the role of disease in the creation of Renaissance culture.

This is a tall order, one that will not be easily filled. But this impressive collection of books provides novel insights and identifies new directions and methodologies for future study. There is still much to learn about the place of disease in the Renaissance, and much to be gained from understanding it better.

NEW MEXICO STATE UNIVERSITY