The Black Death — Part Two
Facing The Black Death With Medieval Medicine
In Part One of this series of articles on The Black Death, I described the ominous portents of doom that heralded the onslaught of the Plague on a terrified, unsuspecting Europe.
By 1348, the Black Death was creeping across Europe like a malevolent ghost, striking fear and despair into the hearts of the population.
This unseen terror, claiming lives with terrifying speed, ripped through the fabric of medieval life, leaving a trail of devastation in its wake. Institutions that formed the bedrock of society — the Church and the feudal governments — were left stunned and helpless, like victims of a dragon’s sudden, fiery rampage.
“It is almost impossible,” wrote a contemporary French chronicler in 1348, “to credit the mortality throughout the whole country. Travellers, merchants, pilgrims and others who have passed through it declare that they have found cattle wandering without herdsmen in the fields, towns and waste-lands; that they see barns and wine cellars standing wide open, houses empty and few people to be found anywhere… and in many different areas, both lands and fields are lying uncultivated.”
Adding another layer of tragedy to this unfolding nightmare was the state of medical knowledge at the time.
While the Black Death brought suffering and fear, it also exposed the limitations and misconceptions of the medieval medical profession. There is nothing in the medical literature of this era suggesting that the treatment of Plague by doctors was ever directly responsible for a cure.
Most argued that flight from the disease was the best possible defence and, if flight was impossible, then prayer was the best remedy.
Gui de Chauliac, the Pope’s physician in France, lamented: “The Plague was shameful for the physicians who could give no help at all, especially since, 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.”
So, what were these blind spots of medieval medicine that hindered the fight against the plague and offered little solace to a society facing this insidious, unknown enemy?
Galen’s Theory of the Four Humors
For centuries, Western medicine had subscribed to the theories of Galen, a Greco-Roman physician whose ideas held sway for over a millennium.
His concept of “humors” — four bodily fluids representing temperament and health — formed the bedrock of medical practice.
Galen believed that all illness was caused by an imbalance of the four humors therefore, the remedy was to rebalance them with the Treatment of Opposites. If, for example, a patient suffered from too much Phlegm (which was seen as cold and wet), the medieval doctor might prescribe a poultice of something containing the opposite properties: something hot and dry, like pepper or mustard seed.
As well as using Galen’s theory for treatment of Plague, medieval physicians also offered theories as to the type of person most likely to suffer and die from Plague.
Pregnant women, those of ‘fragile nature’ and the starving pauper were believed vulnerable. People of hot, moist temperament (Blood humor) were also likely to become victims.
However, (not surprising given the moralistic misogyny of the Roman Catholic Church) the most likely candidates for contracting the Plague were ‘stout young women with a taste for lechery’!
As you can guess, in the face of the virulence of the Black Death, Galen’s theories were basically useless. His focus on the imbalances of bodily fluids did not take into account the real cause of the Plague — the bacterium Yersinia pestis.
Further hindering treatment of the Plague was the rigid control exerted by the Roman Catholic Church.
Medical practices were entirely subject to religious approval. Autopsies, crucial for understanding the disease’s pathology, were unable to be performed due to an edict by Pope Boniface in 1300 forbidding the mutilation of corpses.
This state of affairs left medieval physicians trapped in a cycle of guesswork and totally ineffective treatments.
A Poisonous Miasma
Adding to the confusion was the prevailing belief in Miasma, a poisonous “bad air” thought to spread disease. This misconception led to bizarre, and sometimes counterproductive, practices.
Authorities recommended that houses be filled with pungent herbs and fires burned to purify the air. If a person had to leave the house, it was suggested that they carry a ‘smelling apple:’ pepper, sandalwood, roses, camphor and gum arabic, moulded into the shape of an apple.
While these practices might have made the pungent odours of medieval life a little more bearable, they had little effect on fighting the spread of the Plague!
Bloodletting, Buboes, and Bad Odours
Despite the limitations, physicians weren’t entirely passive. Their arsenal of remedies, though often ineffective, reflected both their understanding of Galenic medicine and the desperation of the situation.
Bloodletting, a mainstay of medieval treatment, was believed to purge the body of harmful humors like an excess of Blood. Sadly, this practice offered no actual benefit against the Plague and likely weakened already vulnerable patients.
Another common practice was lancing or cauterizing the buboes, hoping to draw out the “poison.” Poultices and salves of dubious ingredients, including animal parts and excrement, were applied to these lesions. While some might have offered minor pain relief, their ability to combat the plague was nonexistent.
One particularly peculiar notion held that bad odours could counter the miasma. Physicians and attendants working with plague victims were considered immune, leading some to believe exposure to foul smells offered protection. A local commentator had this to say: “Attendants who take care of latrines and those who serve in hospitals and other malodorous places are nearly all to be considered immune.”
According to other sources of the time, it was not uncommon for the frightened citizens of a plague-struck city to spend hours each day crouched over a toilet, sniffing in the foetid fumes with relish, hoping for protection from the Plague!
Despite these largely ineffective preventions and cures, there were some individuals who dared to challenge the status quo.
Ibn Khatimah, a surgeon from Damascus, attempted to surgically drain the buboes during a specific window, demonstrating a more proactive approach. Others, like Gui de Chauliac, emphasized hygiene and isolation measures, recognising the role of contact in transmission.
While these efforts often yielded little obvious success, they planted seeds for future advancements in medicine.
The Black Death, despite its devastation, served as a harsh catalyst for change by exposing the limitations of existing medical knowledge.
It also led to a shift towards observation, experience, and eventually, a more evidence-based understanding of disease and its treatment.
From Darkness to Understanding
Today, we know the real culprit behind the horrors wasn’t miasma or divine punishment, but a tiny bacterium: Yersinia pestis.
In the late 19th century, French bacteriologist Alexandre Yersin identified the bacterium in Hong Kong during another bubonic plague outbreak.
The critical link to transmission, however, came from another scientist, Joseph P. Manson.
Observing infected rats and the abundance of fleas, he deduced that the breed Rattus rattus (the black rat) carried the plague bacterium in their blood without succumbing to the disease.
Fleas feeding on infected rats became carriers themselves, and when they jumped to humans, they transmitted the bacteria through their bites. This explained the rapid spread of the plague along trade routes, especially through bustling ports where rats thrived.
However, understanding the cause was only half the battle. Finding an effective treatment was the next challenge.
Antibiotics, the modern weapon against bacterial infections, wouldn’t be discovered until the twentieth century after World War I. The first antibiotic, penicillian, was not widely used until World War II.
In the meantime, combating the plague relied on improved hygiene, quarantine measures, and flea control. Rats were culled, houses were cleaned, and international cooperation in tracking and containing outbreaks became crucial.
The mass production of antibiotics in the 1940s finally provided a decisive weapon against the plague.
Streptomycin, the first effective antibiotic, drastically reduced mortality rates. Today, a wider range of antibiotics, including tetracycline and gentamicin, offer even more effective treatment options.
Despite these advancements, the Plague remains endemic in parts of Africa, Asia, and the Americas.
Believe it or not, the bacterium Yersinia pestis is still carried by fleas inhabiting rats, certain rabbit breeds, woodrats, ground squirrels, mice, voles, chipmunks and prairie dogs!
