Disease and the Modern World: 1500 to the Present Day

Mark Harrison

• Publisher: Polity
• Year: 2013
• ISBN:
  9780745638010
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

'Mark Harrison's book illuminates the threats posed by infectious diseases since 1500. He places these diseases within an international perspective, and demonstrates the relationship between European expansion and changing epidemiological patterns. The book is a significant introduction to a fascinating subject.' Gerald N. Grob, Rutgers State University

In this lively and accessible book, Mark Harrison charts the history of disease from the birth of the modern world around 1500 through to the present day. He explores how the rise of modern nation-states was closely linked to the threat posed by disease, and particularly infectious, epidemic diseases. He examines the ways in which disease and its treatment and prevention, changed over the centuries, under the impact of the Renaissance and the Enlightenment, and with the advent of scientific medicine.

For the first time, the author integrates the history of disease in the West with a broader analysis of the rise of the modern world, as it was transformed by commerce, slavery, and colonial rule. Disease played a vital role in this process, easing European domination in some areas, limiting it in others. Harrison goes on to show how a new environment was produced in which poverty and education rather than geography became the main factors in the distribution of disease.

Assuming no prior knowledge of the history of disease, Disease and the Modern World provides an invaluable introduction to one of the richest and most important areas of history. It will be essential reading for all undergraduates and postgraduates taking courses in the history of disease and medicine, and for anyone interested in how disease has shaped, and has been shaped by, the modern world.

1

Disease and Medicine before 1500

In order to understand the significance of the changes wrought by the advent of modernity during the sixteenth and seventeenth centuries, we must look briefly at the world they transformed. This period is generally known as the Middle Ages, or the medieval period, and spans the centuries between the demise of the Roman Empire in the fifth century ad and the new world created by the Renaissance and the Reformation. Until the year 1000 or thereabouts, Europe was a poor, agricultural society with few large towns or cities. Epidemics and famines occurred with dreadful regularity, including the plague, which periodically ravaged Europe and the Near East between 541 and 767.¹ The intellectual glories of Greece and Rome were known only to a few, in monastic orders on Europe’s western fringe, and it was only beyond Europe’s boundaries – in the Byzantine Empire and the Islamic Near East – that classical learning truly flourished. In the West, the intellectual vacuum was filled almost entirely by the Catholic Church and its interpretations of Holy Scripture. But in the three centuries after 1000, Europe became more prosperous and cosmopolitan. Agriculture thrived in warm, stable climatic conditions, and produced enough of a surplus to enable the population to double. The surplus also permitted a flourishing trade in commodities such as wool and wine. Merchants, landlords and artisans prospered, towns grew, and cathedrals and churches were built to the glory of God and their benefactors. Monarchs established their authority over barons and knights, and left many parts of Europe more settled and at peace than before. In Paris and other medieval cities, universities emerged from monastic schools and began to resurrect the ancient scholarship that had been lost in much of Europe since the fall of Rome. In the thirteenth century, Europe was probably better off, better fed, better educated and in better health than at any time since the fall of the Roman Empire.

Disease in the Western medical tradition

Between 1000 and 1300, most European countries were periodically beset by dynastic conflicts, but the relative stability of the ‘High Middle Ages’ permitted intellectual life to flourish in a way that it had not for centuries. This was as true of medicine as of other branches of learning. Until the eleventh century, medicine had seldom been taught in monastic schools, and in the few instances where it was part of the curriculum, it was taught alongside other areas of natural knowledge. The object was not to produce a class of healers, but to enable monks to better understand the works of God. All this began to change at Salerno towards the end of the eleventh century. Salerno was a Norman dukedom in what is now southern Italy. Lying at the intersection of several important trade routes between Europe, Byzantium and the Arab world, it developed as a cosmopolitan centre of learning, and it was through Salerno that classical Greco-Roman medicine began to re-enter mainland Europe. For many years after the fall of the Roman Empire, little was known of the medical writings of antiquity, such as the Hippocratic corpus (fifth–fourth centuries bc) and the many works of Galen of Pergamum (ad 129–216). But in the Arab world, these works were still widely used and had been translated into Arabic. Several scholars had added to them, most notably Rhazes or Razi (d. 925) and Ibn Sina, known to the West as Avicenna (d. 1037). These writers were interested in the philosophical as well as the practical dimensions of medicine, and Avicenna systematized Galenic medicine by placing it within an Aristotelian philosophical framework.²

The Arabic literature that entered Europe through Salerno soon began to attract the attention of scholars throughout the Italian peninsula. Constantine the African (c.1020–87) is perhaps the best known of these, and translated many Arabic medical works into Latin, the lingua franca of Catholic Europe. In the first half of the twelfth century, Greek and Roman works (which had been rendered into Arabic), together with some Arabic originals, became widely known in the monasteries of Italy, and a new canon of medical authority emerged in the form of the Articella, or ‘Little Art of Medicine’. Simultaneously, in Spain, which had experienced several centuries of Moorish rule, there was a great deal of additional translation of medical and philosophical works from Arabic into Latin. The texts translated included the Canon of Avicenna and the works of Rhazes. Translators in Spain imparted an even greater Aristotelian slant to medicine than those in Italy. Following the synthesis between classical philosophy and Christian doctrine by Thomas Aquinas (1225–74), Aristotelianism was to become the main philosophical system underpinning Christian teaching in the West. Aristotle’s ‘Prime Mover’ was equated with the Christian God, while, in medical texts, the purpose of organs and other bodily structures was said to be God-given. This new way of thinking aroused curiosity about the body, because it seemed that its design could reveal the mind of the Creator.

The learned medicine that had been recovered for the West was taught in a systematic way in the monasteries of the Catholic Church, and later in the universities that emerged from monastic schools. The first of these was the University of Bologna, founded around 1180, which was quickly followed by universities in Paris (c.1200), Oxford (c.1200), Salamanca (c.1218), Montpellier (c.1220) and Padua (c.1220). In all, fifty universities were founded between 1180 and 1479. Although its temporal power was increasing at this time, the Church did not interfere too much with the teaching of medicine. For example, it permitted the dissection of human bodies when this was introduced into the curricula of some universities during the fourteenth century. As medical knowledge became more systematized, it was offered as a separate degree. The MB, or bachelor of medicine degree, was taken after a preliminary period of training in philosophy and the arts (the MA degree), and took around seven years in total. The MD, or doctor of medicine degree, was a more advanced qualification taken after at least ten years of study. In view of the long period necessary to qualify, few students opted to read for either degree. At Oxford in the fifteenth century the average was one student every two years! The exception was the University of Padua, where medical students comprised around 10 per cent of the student body (around nine per year). By the mid-fifteenth century Padua had acquired an excellent reputation for practical learning, whereas northern European universities tended to be more clerical and theological in outlook.³

The system of medicine taught at these universities through to the end of the fifteenth century was essentially Galenic and Hippocratic, as understood from recent translations of Arabic texts. At the core of this system was the humoral theory of disease, which originated in the writings of Hippocrates and his followers on the Greek island of Cos. Rather than attributing disease to the action of gods and spirits, the Hippocratics sought natural explanations, grounded in the relationship between human beings and their environment. The central Hippocratic idea was that the body was composed of fluids known as humours. Initially, there were thought to be three humours – blood, bile and phlegm – but over time practitioners began to differentiate between two types of bile, yellow and black (also known as melancholy). When the four humours were in balance, the body was deemed to be healthy; when out of kilter, it became diseased. Each humour was closely associated with a particular season of the year: blood with spring, summer with yellow bile, autumn with black bile, and winter with phlegm. Further associations were made with the four ages of man (childhood, adolescence, maturity, old age), with the four elements (earth, fire, air and water), and, in medieval times, with the four Evangelists (Matthew, Mark, Luke and John).⁴ This complex network of associations helps to explain why the humoral system endured for so long. In a predominantly agricultural society, the link between the body and the seasons made sense, while the accretion of other meanings made it compatible with Christian theology.

Medical practice and medical institutions

For university-trained physicians, the treatment of disease consisted in correcting or preventing an imbalance between the humors. Such an imbalance could occur for any number of reasons. Certain seasons of the year tended to produce an excess of one humour, giving rise to characteristic symptoms; for example, spring was said to bring about an increase in blood, sometimes culminating in fever. Certain forms of behaviour could have the same effect: an inactive life-style could produce an excess of the heavy, watery humour, phlegm; too much activity, on the other hand, stirred the blood, inducing fever – hence the expression ‘feverish activity’. Each individual was also born with a propensity to produce too much of one humour, making them liable to certain diseases. Someone with too much black bile, for example, was said to have a ‘melancholic’ disposition, with a tendency to sadness and depression. To counteract their tendency to disease, an individual might be prescribed a regimen of diet and exercise of a contrary kind. A phlegmatic person, for example, might be asked to avoid cold and heavy food and to eat light meats and vegetables. Physicians also prescribed depletive treatments such as bleeding, vomiting and purging to take off ‘corrupt’ or ‘excessive’ humours, or tonics to stimulate the production of deficient humours.

In the later Middle Ages, the system of humoral medicine was taught using such influential authorities as Galen and Avicenna. It was chiefly through their eyes that the writings of the Hippocratics and other Greek physicians were seen. As well as offering their own interpretations and opinions, these writers added a good deal that was new. Galen, who is credited with at least 350 works, wrote extensively on the philosophy of medicine, on anatomy and physiology (based mostly on animal dissections), and on the diagnosis of disease. Only a small number of Galen’s works were known to scholars and physicians in the Middle Ages, but his example inspired some to innovate and make independent observations in areas like anatomy.⁵

The physicians comprised a tiny minority of those who made a living from healing in medieval Europe. They often worked in conjunction with apothecaries, who supplied them with drugs, but apothecaries also practised independently, and some made a very good living indeed. The number of apothecaries appears to have increased enormously in the fifteenth century, because the use of medicaments (as opposed to dietetic medicine) became more fashionable, and because of the importation of exotic new drugs from the Orient. Barber-surgeons were equally numerous, their red and white poles denoting one important part of their trade – the therapeutic letting of blood. They also performed small operations such as the removal of bladder and kidney stones. Most barber-surgeons learned their trade as apprentices for five or six years, before going on to practise in their own right. Only in a few places, such as the Italian university of Padua, was surgery offered as an academic subject. Below the barber-surgeons and apothecaries were a multitude of healers, most of whom practised their trade alongside another occupation. These included bone-setters, experts in stone cutting and eye diseases, midwives, astrologers, priests and sorcerers. But the most common resort for the majority of those who fell sick was someone in their family or village who was skilled in making remedies from local plants. Only in a handful of cities such as Freiburg was there any attempt to restrict or regulate medical practice as such, although some cities passed laws regulating the conduct of apothecaries, who were often suspected of fraudulently selling medications.⁶

From the eleventh century, provision was also made for the care of the sick within institutions. The trend began with the charitable actions of members of lay religious brotherhoods and Augustinian canons, who unlike members of monastic orders, were not required to withdraw from society. The infirmaries and charitable houses they established were a response to the growth of cities at this time, and to growing numbers of destitute sick. These institutions were soon joined by a variety of hospitals founded by kings, bishops, lords, merchants, guilds and municipalities. They were endowed as charitable institutions and staffed by members of various religious orders, including the Knights Hospitallers of St John of Jerusalem. In most cases, nursing and medical treatment was performed by members skilled in physic who did not, however, possess any qualification. But by the thirteenth century, many hospitals had one or more trained physicians, and in some Italian cities they were funded by the state.⁷

The term ‘hospital’ (hospitale in Latin) embraced four main types of institution: almshouses, hospices for poor wayfarers and pilgrims, infirmaries for the sick poor, and leper houses. The latter were among the earliest hospitals founded in many countries, despite the fact that leprosy was widely regarded as incurable. It was a disease rich in biblical symbolism and one to which the Christian West gave a disproportionate amount of attention. The appearance of its victims marked them out clearly from the rest of the population. The symptoms included scaly skin, a gruff rasping voice, collapsed tissues, loss of extremities such as fingers, and degeneration of bones. In the absence of any reliable form of diagnosis, it is impossible to say whether those termed ‘lepers’ in the Middle Ages had actually contracted Hansen’s disease, as it is now termed. It is quite likely that many were suffering from chronic skin complaints. We have no way of knowing for certain, but this does not prevent us from trying to understand how contemporaries viewed leprosy and how those designated as lepers were treated. Almost invariably, this entailed isolation from the rest of society, whether they were confined in special communities or left to wander in search of alms. Either way, lepers were required to wear special clothing and to warn others of their approach with a bell or rattle. From 1100 the preferred solution was to isolate lepers in special houses (leprosaria) outside towns, normally without any assistance except food and shelter. Although each house was small in size, the number of leprosaria was large: by 1226, France had around 2,000 such institutions, and by 1250, England had 130.⁸ The rapid growth in leper houses has led some historians to the conclusion that Christian society had a mania for persecution – a desire to segregate and punish that was later vented on the poor and the mad.⁹

The segregation of lepers was justified on the grounds of the biblical injunction in Leviticus 13.46 that the ‘unclean’ should dwell outside the camp, and in 1179 the Third Lateran Council ordered that all lepers be cast out of society. What, then, was so ‘unclean’ about the leper? One common misconception is that leprosy has always been regarded as a ‘contagious’ disease, in the sense that it could be passed easily from person to person. This was far from the case. To the extent that leprosy was seen as contagious, it was in the sense that lepers corrupted the air around them, exposing others to similar corruption. But such explanations do not appear to have existed until the thirteenth century, several decades after the order from the Third Lateran Council. Far more common was the view that lepers were unclean because of some form of moral contamination. More than most diseases, leprosy was associated with sin, at least in the Jewish and Christian traditions. In the Middle Ages it was closely linked with the sin of lust, which led some churchmen to claim that the disease was spread sexually. Leprosy served alongside other diseases as a way of condemning forms of behaviour proscribed by the Church, which was attempting to exert more control over the lives of ordinary people, most of whom probably had few sexual inhibitions. Prostitution, for example, was an openly accepted feature of medieval life. But along with other ‘evils’...

Table of contents

• Cover
• THEMES IN HISTORY SERIES
• Title page
• Copyright page
• Acknowledgements
• Introduction
• 1 Disease and Medicine before 1500
• 2 Early Modern Europe
• 3 Disease and Social Order: The Enlightenment and its Legacy
• 4 The World beyond Europe
• 5 Disease in an Age of Commerce and Industry
• 6 The Individual and the State
• 7 Disease, War and Modernity
• 8 Health for All? Affluence, Poverty and Disease since 1945
• Glossary
• Select Bibliography
• Index