Disease and the Modern World: 1500 to the Present Day E-Book

Mark Harrison

• Herausgeber: John Wiley & Sons
• Kategorie: Wissenschaft und neue Technologien
• Serie: Themes in History
• Sprache: Englisch

Seitenzahl: 559

Veröffentlichungsjahr: 2013

Beschreibung

‘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.

Leseprobe

Table of Contents

Cover

THEMES IN HISTORY SERIES

Title page

Copyright page

Acknowledgements

Introduction

1 Disease and Medicine before 1500

Disease in the Western medical tradition

Medical practice and medical institutions

The world the plague made

2 Early Modern Europe

The ‘Great Pox’: syphilis

Plague

Medicine and the ‘new science’

3 Disease and Social Order: The Enlightenment and its Legacy

Disease prevention: public and private spheres

War, disease and medicine

The retreat of plague

4 The World beyond Europe

New World peoples, Old World diseases

The slave trade and the Atlantic exchange

Disease among Europeans

5 Disease in an Age of Commerce and Industry

Smallpox and the vaccination controversies

Quarantine, commerce and political economy

Cholera and the tensions of modernization: the epidemics of 1830–1832

Urban disease and sanitary reform

6 The Individual and the State

Disease and scientific medicine

From consumption to tuberculosis

The third plague pandemic: an imperial crisis

Tropical diseases

Microbes and migrants

Mortality decline

7 Disease, War and Modernity

Health and medicine in an age of total war

The influenza pandemic of 1918–1919

Typhus

Malaria

Sexually transmitted diseases

8 Health for All? Affluence, Poverty and Disease since 1945

Disease in affluent societies

Disease, poverty and environment in the developing world

Epilogue

Glossary

Select Bibliography

Index

THEMES IN HISTORY SERIES

Published

M. L. Bush, Servitude in Modern Times

Peter Coates, Nature: Western Attitudes since Ancient Times

Mark Harrison, Disease and the Modern World: 1500 to the Present Day

Colin Heywood, A History of Childhood: Children and Childhood in the West from Medieval to Modern Times

J. K. J. Thomson, Decline in History: The European Experience

David Vincent, The Rise of Mass Literacy: Reading and Writing in Modern Europe

Copyright © Mark Harrison 2004

The right of Mark Harrison to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

First published in 2004 by Polity Press Ltd.

Polity Press

65 Bridge Street

Cambridge CB2 1UR, UK

Polity Press

350 Main Street

Malden, MA 02148, USA

All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.

A catalogue record for this book is available from the British Library.

Library of Congress Cataloging-in-Publication Data

Harrison, Mark, 1964

Disease and the modern world: 1500 to the present day / Mark

Harrison.

p. cm. – (Themes in history)

Includes bibliographical references and index.

ISBN 0-7456-2809-5 – ISBN 0-7456-2810-9 (pbk.) – ISBN 978-0-7456-3802-7 (Single-user ebook) – ISBN 978-0-7456-3801-0 (Multi-user ebook)

1. Medicine – History. 2. Diseases – History. I. Title. II. Series:

Themes in history (Polity Press)

R131.H247 2004

610'.9'03 – dc22

2003017371

For further information on Polity, visit our website: www.polity.co.uk

Acknowledgements

Like any other synthetic work intended as a textbook or for the general reader, this book depends heavily on the scholarship of others, and I would like to acknowledge my great debt to them. One book that I would have liked to have made more use of was Howard Phillips and David Killingray’s volume on The Spanish Influenza Pandemic, which I did not receive until my manuscript had reached the copy-editing stage. Although I have referred to this book in chapter 7, I was unable to incorporate its many insights. Readers with a particular interest in the influenza pandemic would do well to consult this book, which contains some of the best work yet produced on the subject.

I am lucky enough to know or to have known many of the scholars who produced the original scholarship upon which this book is based, among whom I would like to mention the late Roy Porter, who provided me with invaluable advice when I began writing this book. I owe an even greater debt to my friend and former colleague Michael Worboys, who has probably done more than anyone else to influence my thinking about disease. I would also like to thank Loreen Salleh and the referees for their helpful suggestions, and the people at Polity for their assistance, especially Jean van Altena for her excellent copy-editing. Finally, I would like to thank my family, friends and colleagues for their forbearance and support.

Introduction

Today, every country may be regarded as modern in its most fundamental respects. The very fact that we can compare a country’seconomic performance, its population and its mortality figures is evidence of this. Virtually every nation on earth is organized in a way that enables its resources to be measured, monitored and evaluated – in other words, a form of organization that is typically modern. Countries that have undergone modernization may continue to contain pre-modern social arrangements or ideas, but only if they are compatible with the key elements of modernity.1 The intrinsic features of modernity according its most famous analyst, Max Weber, were the rise of capitalism, the dominance of reason over faith, and the organization of society along bureaucratic lines. All were aspects of a process that Weber referred to as rationalization: a form of reasoning in which every aspect of human life became subject to calculation, measurement and control. By the nineteenth century, according to Weber, rationalization had stripped away community feeling, religious belief and moral value, and had replaced them with legal, political and economic regulation.2

Some may object that modernity is now a thing of the past, and that we are living in a postmodern world in which reason is no longer the guiding light and in which technology has lost its redemptive power. But while there are some reasons to see the recent past as distinctive, a historian of the long term may be more cautious. From the Renaissance onwards, successive generations of intellectuals have found the need to label their own times as different or special. Like Agnes Heller, I think it makes more sense to see postmodernism not as something that comes after modernism but as a critical, reflective tendency within it; a tendency that comes to the fore from time to time, questioning our ability to understand the world and our capacity to make it after our own image.3 In any case, it would be a mistake to exaggerate the changes that have occurred over the last two decades or so, as there is little sign of any fundamental shift in patterns of social organization. For good or ill, we are still very much part of the modern world.

Modernity is clearly a problematic concept, and there may be drawbacks to using it as a central theme for a book on the history of disease; nevertheless I believe, like Fernand Braudel, that a general history requires ‘an overall model, good or bad, against which events can be interpreted’.4 I aim to show that disease was central to the development of modern states and their machinery of government. From the Renaissance onwards, the control of disease became one of the most important functions of the state, along with the protection of its people from external aggression. Thus the threat of plague and other diseases met with co-ordinated state action in the form of quarantine, medical relief, isolation of victims, and measures to cleanse the environment. One cannot entirely discount humanitarian motives for these measures, but the growth of state activity had much to do with a new perception of the economic and military value of the population. This perception may, itself, have owed much to the depredations of plague, which increased the scarcity and price of labour. Public health measures also developed as means of controlling potentially dangerous or unruly elements within society, such as soldiers, beggars and prostitutes, all of whom were stigmatized as bearers of disease. The scale and scope of these measures widened considerably in the coming years, with the state aiming to maximize the potential of its population.

At numerous points, the history of disease also illuminates the growth of capitalism and its corollary, the formation of a new kind of class society. For one thing, disease rapidly became a marker of class: mortality differed greatly among social groups, as did the kinds of disease they tended to suffer from. In the Renaissance and for much of the seventeenth century, plague appeared to show a ‘preference’ for the poor, rather like cholera in the nineteenth century. Gout, by contrast, was a disease of luxury and a marker of wealth and status; and disease is still one of the most poignant indications of a world divided by inequalities of wealth and opportunity. In rich, ‘Western’ countries, most people live well beyond seventy years of age and die from heart disease, cancer or degenerative diseases. In the poor countries of Asia, Africa and Latin America, life expectancy is far lower, with many dying in infancy from infectious diseases and, increasingly, from AIDS and AIDS-related illnesses. There, the vast majority of people are denied the basic sanitary and medical provisions of those who inhabit the developed world.

Another aspect of economic development that looms large in this book is the global expansion of the market economy and of capitalist systems of production. This process began in the sixteenth century with the colonization of parts of Asia and most of central and southern America by the Spanish and the Portuguese, and was boosted during the seventeenth century with the arrival of commercial fleets from Holland, England and France. During the eighteenth century, these trading concerns began to transform themselves into territorial powers and to establish dominions in parts of South and South-East Asia. The trading companies were gradually brought under stricter control, and their territories came to be administered directly by European states. In the nineteenth century, there was a fresh wave of colonial expansion, most notably in Africa, from the 1880s. Alongside these ‘formal’ colonies, European countries enjoyed unequal terms of trade with poorer, independent nations that formed part of an ‘informal’, commercial empire.5 With the demise of formal colonial rule in the second half of the twentieth century, the informal empire of old set the pattern for new relationships between rich and poor countries. Transnational companies also came to exert a tremendous influence over the economic policies of independent nations, which feared the withdrawal of capital investment.

The emergence of a global economy since the sixteenth century has been one of the most striking and definitive features of the modern world. The economic fortunes of the imperial ‘core’ (which lay in Europe for most of this period) were in large measure dependent upon the exploitation of colonized (‘peripheral’) nations, and for some time on a system of formal slavery.6 Whether or not similar patterns of exploitation have persisted beyond the end of colonial rule is a moot point. Some economists and historians maintain that the life-style enjoyed by rich nations like the USA continues to depend upon the poverty of other countries, while others claim that poor countries have only themselves to blame.7 Either way, these global connections are integral to many chapters in this book. European expansion was in large part facilitated by the spread of Old World pathogens to the New World, while the presence in many tropical countries of diseases deadly to Europeans encouraged the use of African slave labour. But few diseases spread from the New World to the Old, the only important exception being syphilis, which had a profound effect upon European medicine and culture.

By the nineteenth century, the emergence of new technologies such as the steamship and the railway had revolutionized travel and made possible more frequent connections between different parts of the world. In the 1840s, for example, it was possible for a steamship to reach Britain from its Caribbean colonies in about a week, whereas the journey would formerly have taken several weeks under sail. The increasing speed and frequency of contact between different parts of the world served as a further stimulus to the movement of pathogens. In the early nineteenth century, cholera spread from India across much of the world, and at the close of the century, bubonic plague travelled rapidly from southern China to Hong Kong, India and many other parts of the globe. At the end of the First World War, massive and rapid population movements helped to transmit the deadly virus causing the influenza pandemic of 1918–19, which claimed the lives of at least 25 million people. In our more recent past, the advent of air travel has opened up the frightening possibility of virulent strains of influenza or ‘new’ infections like Ebola and Severe Acute Respiratory Syndrome (SARS) spreading beyond their places of origin in a matter of hours.

Globalization has affected the history of disease in other ways, too. During the twentieth century, the rise of international health organizations such as the League of Nations Health Organization and the World Health Organization (WHO) have led to universal expectations of health standards acceptable in a civilized society. Infant mortality rates and what has become known as the ‘human development index’ have become key measures of progress and national pride. Organizations such as the WHO have also led global efforts to tackle disease, most notably the successful campaign to eradicate smallpox. The idealistic rhetoric of the immediate post-war period has moderated, but global targets are still a feature of disease prevention today.

As well as the material fabric of the modern world, we must also consider the intellectual changes that, for many historians and sociologists, are characteristic of modernity. During the Renaissance, more value began to be placed on direct observation and experience. Although stimulated by the rediscovery of ancient texts, this desire to see the world anew culminated in the modification or rejection of old authorities – a process that led to the Scientific Revolution of the seventeenth century and, later, to the Enlightenment. New ways of knowing came into being, such as those based on experimentation and quantification; tools like the microscope opened up new vistas in the natural world; and new idioms were developed to describe and classify natural phenomena.8 As a result, the natural world was shorn of much of its magical and religious symbolism – a process that Weber described as ‘disenchantment’. Disease came increasingly to be seen as a natural entity that could be understood and cured in wholly natural ways. By the end of the seventeenth century, it was unusual for a physician or anyone educated in natural philosophy to ascribe an outbreak of disease to divine retribution.

In the course of the eighteenth century, diseases came to be classified much as any other natural phenomena. As well as closely observing the symptoms of various diseases, medical practitioners began to look inside the body and to locate disease in particular organs, then in tissues, and, by the nineteenth century, in individual cells. Disease changed from being a generalized disorder of the body to a thing possessing a characteristic pathology. During the second half of the nineteenth century, the discovery of the causal organisms of many bacterial and parasitic diseases established a new paradigm for medicine and for thinking about disease. The laboratory became the arbiter of whether a disease existed and, increasingly, the source of new medicines and vaccines that could cure or prevent specific infections. Germ theories of disease continue to influence the way people think about all kinds of illness, including what are generally known as mental diseases, although some critics regard these germ-based models as inappropriate and simplistic.9 The identification of genes related to specific diseases has also led many people to think about disease in narrow, reductionist ways, although geneticists themselves frequently stress that environmental factors are often crucial in determining if or when a trait is developed.

As a way of thinking and a mode of social organization, modernity has tended to sweep all before it, but it would be wrong to give the impression that its march entailed a simple diffusion of Western ideas and technologies. The reality as it pertains to disease and medicine, as in so many other areas, is far more complex. Modern ideas of disease emerged in some regions of the world as the result of a dialogue – albeit usually an unequal one – between Western medical practitioners and those of indigenous systems of medicine, such as Chinese medicine, Ayurveda (the Hindu medical tradition) and Unani-tibb (Islamic medicine). All parties have been changed to some extent by this encounter.10 Western practitioners were changed less, but they acquired a vastly larger repertoire of therapeutic practices and medicines as a result. Indigenous or ‘traditional’ medical systems were also changed, and most came to incorporate some aspects of Western medicine, such as physiology and anatomy, which subtly altered conceptions of disease and its treatment. While Western medicine has become the dominant system in most parts of the world, these other systems have continued to flourish, sometimes with state support. Thus, in many parts of the world – including now in the West – it is possible to consult a range of practitioners for the same ailment and to be invited to consider disease in radically different ways. This heterogeneity is, perhaps, a facet not so much of postmodernity but of a global world fashioned by the process of modernization.

The relationship between disease and the rise of the modern world is probably most obvious if we examine the history of infectious diseases, particularly epidemic diseases, which have been among the principal threats to the order and prosperity of modern states. But both these terms – ‘infectious diseases’ and ‘epidemic diseases’ – are highly problematic, and some definition of what I understand by them is necessary. By ‘infectious diseases’, I mean those diseases that are thought to arise outside the body, whether in a corrupted atmosphere, or as a result of contamination from an ‘infected’ article or person. This broad definition encompasses the varied and changing meanings of the term ‘infection’, which have ranged from person-to-person transmission to the idea that disease was generated by rotting matter. The term ‘infection’ is practically synonymous today with the term ‘contagion’, and it is sometimes difficult to distinguish between them historically, too. But ‘contagion’ has generally had a more specific meaning, referring to the transmission of disease from person to person, and so is less serviceable as a focus for a general work of this kind. The term ‘epidemic’, which is also sometimes used in this book, is another elastic category and defies precise definition. Like the terms ‘infection’ and ‘contagion’, it has a long history stretching back to the ancient Greeks, and has been used loosely to refer to serious outbreaks of disease that are localized in time and space. Writers in the Hippocratic tradition used to use the term ‘epidemic’ to refer to peculiar ‘constitutions’ of the atmosphere that produced distinctive sets of maladies, but now the term is generally used to denote an incidence of disease that is above the statistical norm.

As if these problems were not enough, there is little agreement about the concept of disease itself. Historians, philosophers, doctors, sociologists and anthropologists have all grappled with the problem of disease, but no one has been able to produce a definition that has satisfied all. They even disagree about whether disease is a real entity that can be verified scientifically.11 Some, like Christopher Boorse, believe it is possible to distinguish between ‘disease’ (which can be objectively verified) and ‘illness’, which cannot.12 ‘Disease’ in this sense is sometimes defined as a deviation from the biological norm, and sometimes as an impediment to survival and reproduction. As a tool of analysis, this distinction has its uses: it acknowledges that illness has a biological and a social component, and it allows us to acknowledge the reality of suffering among non-human animals. But it does not resolve the problem of the specificity and existence of particular diseases – what is sometimes known as their ontological status. There are many conditions such as myalgic encephalomyelitis (ME) and various ‘mental diseases’ that might be said to impair survival but which cannot be easily verified. The same is true of Alzheimer’s disease and other degenerative disorders, which manifestly impair bodily function. Are these distinct diseases or parts of the natural ageing process? In other words, while impairment of function can easily be identified, the existence of conditions such as ME cannot. Definitions of disease that are derived from statistical norms can also lead to anything unusual being described as a disease, even when it might not be unhealthy; some abnormalities may even enhance an organism’s chances of survival or reproduction.

This ‘realist’ approach to the problem of disease differs markedly from that of those who contend that all diseases – physical and ‘mental’ – are culturally specific and value-laden, an approach more common among anthropologists and sociologists than among physicians. The disease/illness distinction makes little sense to those who believe that all disease is subjective, for they believe that disease cannot be isolated from its social and cultural context. The distinction rests, they argue, on an ideal of scientific purity that has never been attained.13 Some sociologists go even further and argue that just as diseases are ‘constructs’ of medicine, so ‘objectivity’ itself is a construct of sociology. Objectivity in other words has no objective existence!14 If so, one wonders why we should take any arguments seriously, including those that deny the objectivity of disease.

However, there have been some attempts to reconcile these conflicting traditions. One such is the work of Charles Culver (a psychiatrist) and Bernard Gert (a philosopher), who see both ‘biological’ and ‘cultural’ elements of disease as fundamentally linked. Gert and Culver envisage disease as part of a more general category that they term ‘maladies’, including injuries, disabilities and death. Each society, they argue, has a rather different interpretation of these maladies, and it is only if a particular person or society perceives them as ‘evil’ that they can be classed as a disease. For example, what might be regarded as a dangerous mental state in one culture might be welcomed in another as a sign of divine inspiration. Such sensitivity to cultural contexts is very appealing, especially to many historians and anthropologists, yet it presents certain difficulties. What happens, for example, when society does not recognize a dysfunction that impairs someone’s health? There are many examples throughout history that testify to this problem, where sick individuals have been neglected or even stigmatized because their illness has not been socially legitimated.

These are weighty and perhaps intractable problems, but they have to be confronted at some level by historians of disease. Whether or not we think that disease has an objective existence affects what we are prepared to say about it and what kind of histories we aim to write. Is it valid, for instance, to write the history of a particular disease – such as plague or malaria – when what has been understood by these terms has changed markedly over time? Can historians ever be sure that they are writing about the same disease as people in the past? Does it matter what a disease really was, or are society’s responses to it all that should concern us?

Historians of medicine have been aware of these problems for many years. As early as the 1930s, the German historian Ludwik Fleck drew attention to the dangers of assuming a constant identity to disease when discussing the case of syphilis in his path-breaking book, The Genesis and Development of a Scientific Fact. The term ‘syphilis’ was rarely used before the nineteenth century, so this makes it problematic to write histories of ‘syphilis’ that stretch back to its apparent origins in Europe in the 1490s.15 But with a few notable exceptions,16 the vast majority of historians have been less cautious. Some have thought nothing of writing histories of disease that span many centuries,17 and many have set out with the express aim of identifying the ‘true’ causes of mortality in the past, retrospectively diagnosing disease on the basis of contemporary descriptions of symptoms and patterns of mortality. But this way of writing the history of disease was challenged in the late 1970s by historians influenced by the sociology of knowledge, and particularly the work of sociologists based at the University of Edinburgh.18 From the ‘Edinburgh School’ came the notion that scientific and medical knowledge was ‘socially constructed’, and not a simple reflection of ‘reality’. Knowledge, in other words, was produced rather than discovered.

Historians indebted to the Edinburgh School have argued that medical knowledge has typically served professional and political interests. This comes through strongly in Karl Figlio’s influential study of chlorosis, or the ‘green sickness’, so-called because of the severe anaemia that gave those afflicted a greenish pallor. The condition was frequently diagnosed in nineteenth-century Britain, but had largely disappeared by the 1920s. Figlio argued that the reason lay in fashions of diagnosis that reflected the relationship between classes in Victorian Britain. Capitalist development, he argued, was facilitated by the exploitation of youthful female labour, which led to great social value being attached to work, and stigma being attached to idleness. Chlorosis, which was typified by debility, was idleness in pathological form, a disease that amplified all the characteristics of the ‘delicate’, idle adolescent.19

Figlio’s article was followed by many other explorations of the relationship between disease and professional or political power,20 perhaps the most notorious of which is François Delaporte’s history of the Paris cholera epidemic of 1832. Delaporte boldly asserts that ‘“disease” does not exist’, and that it is ‘illusory to think that one can “develop beliefs” about it or “respond” to it’. ‘What does exist is not disease but practices,’ he claims.21 However, Delaporte is not actually denying the existence of the causal organism of cholera, but is emphasizing – in a rather sensational way – that human beings can know the world only through concepts, and that it is impossible to draw a distinction between disease and cultural practices. Our culture, in other words, actively forms our idea of what a disease is. In the case of cholera in 1832, Delaporte argued that disease practices were structured by prevailing power relationships, traditional humoral thinking about disease giving way to new theories which stressed the role of the lower classes in the generation and spread of cholera.

Delaporte’s work owes a great deal to that of Michel Foucault, which, in recent years, has provided the basis for many ‘social-constructionist’ studies in the history of medicine. He takes from some of Foucault’s earlier works the insight that knowledge is inextricably bound up with power, and employs a methodology similar to that of Foucault in The Archaeology of Knowledge. Foucault’s Discipline and Punish has also proved influential, especially upon historians who have examined disease concepts and hygienic practices in modernizing countries. For example, the growing emphasis upon indiscipline and sloth as causes of disease has been seen as characteristic of the transition from paternalistic to capitalistic societies, just as attempts to control disease have increasingly entailed impersonal forms of discipline and surveillance.22 Foucault’s work has also provided the inspiration for some recent work on disease and identity. His later work on sexuality and ‘the care of the self’, for example, has suggested new ways in which to explore the subjective experience of disease, and historians are beginning to examine how notions of individuality are bound up with ideas of disease and its transmission.23

These approaches meld easily with those of historians who have employed anthropological insights into pollution and contagion. Historians have shown particular fondness for Mary Douglas’s work, most notably her book Purity and Danger, which was first published in 1966. Strictly speaking, the book is more concerned with concepts of pollution than with disease, although they are fundamentally linked. She argues that Nature (in the form of disease) is often invoked to sanction or prohibit violations of a society’s moral order. Thus, particular types of disease are interpreted as punishments for the transgression of what a society regards as its moral boundaries; these transgressions have included adultery, incest, disloyalty to the tribe or ruler, and blasphemy. Douglas’s work shows that certain moral and social rules are upheld and defined by the belief in contagion. It also tells us a good deal about hygienic practices and other measures taken to prevent or dispel disease. Rather than interpreting these in a strictly materialistic way, as was the fashion among anthropologists in the early twentieth century, Douglas argued that hygienic practices had a ritualistic element. Thus ‘dirt’, in her opinion, is basically ‘matter out of place’, and modern notions of dirt, which are closely associated with disease, have something in common with older ideas of ritual pollution.24 In both modern and pre-modern societies, she argues, hygienic practices have symbolic meanings: they are ways of ordering and classifying our world, even if the forms of these rituals bear little resemblance to one another. Douglas’s insights continue to inspire a great deal of historical work on disease, and have been fruitfully combined with concepts fashionable in the new discipline of Cultural Studies.25

Another strand of writing on disease stems from the Actor Network Theory of Bruno Latour. Latour’s approach is in some ways reminiscent of the sociology of knowledge, because it sees knowledge formation as a social process.26 However, it differs radically, in that it abandons ‘interest-based’ accounts of scientific knowledge in favour of a more complex model that allows for simultaneous points of interaction and influence, and the formation of alliances. Latour also stresses the importance of non-human elements in this process, and employs the term ‘actants’ to describe them. Actants can include all autonomous figures that comprise the material world, including microbes, technologies and ideas. According to Latour, ‘No actant is so weak that it cannot enlist another. Then the two join together and become one for a third actant….An eddy is formed, and it grows by becoming many others.’27 As a result, networks of actants emerge, each connected with many others, simultaneously depending on and influencing one another. Through these networks, ideas, observations, skills and interests are transformed into statements in line with a particular argument: a process of translation in which allies are identified, shaped and enrolled. According to Latour, it is in this way, and not through the force of logic or powerful interests, that scientific ideas are formed and come to dominate, including ideas about disease. Indeed, the case study used by Latour was the rise of Pasteurian germ theories of disease in France. According to Latour, Pasteur’s ideas gained acceptance because he was able to form alliances with various groups, ranging from farmers to military doctors, who came to see Pasteurian ideas as compatible with their own interests and outlook.

One thing that Latour emphasizes strongly is that even material objects must be regarded as actants, as players in their own right. Thus even microbes have the capacity to shape knowledge about disease and to redirect it. It is a view that goes somewhat against the grain of social-constructionist approaches, because it reasserts the primacy and irreducibility of the material world; but it also comes close to attributing agency to non-human subjects, something that many historians find difficult to accept.28 Latour has also been criticized for misrepresenting what sociologists of knowledge understand by ‘interests’, by equating them with the self-proclaimed goals of scientists. However, most sociologists and historians do not take such statements at face value, and see interests as the socio-political factors that have a bearing on an individual’s thoughts and actions.29 Thus, while Latour avoids the pitfalls of crude determinism, he closes off a potentially fruitful line of inquiry.

Many historians share Latour’s view that knowledge cannot be reduced to social relations alone, and few now call themselves ‘social constructionists’. Some refer to themselves simply as ‘constructionists’, a term which suggests that scientific knowledge has to be actively manufactured but which lacks the political connotations of much earlier work in the sociology of knowledge. Many also regard the term ‘social’ as redundant, because all knowledge is in some sense social.30 Others, like the historian Charles Rosenberg, have dispensed with the term ‘construction’ altogether. Rosenberg argues that the ‘social-constructionist’ approach has simplified medical knowledge, making it seem like a mere rationalization of the prevailing order. He further points out that constructionists have focused on a handful of spurious diagnoses such as hysteria and chlorosis, for which a pathological mechanism has not been or cannot be proved. The social constructionists, in other words, have chosen easy targets.

Rosenberg insists that disease and disease practices are shaped to a significant extent by biological reality: different pathogens and different symptoms, he argues, tend to elicit different responses.31 As an alternative to ‘construction’, he has proposed the metaphor of ‘framing’, which recognizes the biological reality of disease while acknowledging that disease does not exist as a social entity until it has been named and explained. This is quite different from saying that the meaning of a disease is determined entirely by social factors: ‘Biology’, Rosenberg insists, ‘shapes the…choices available to societies in framing conceptual and institutional responses to diseases: tuberculosis and cholera, for example, offer different pictures to frame for society’s would-be framers.’32

The metaphor of ‘framing’ has proved popular with those historians who find the notion of ‘construction’ too contrived, and among those who see the ‘biological’ aspects of disease as to some extent shaping ‘social’ responses. But historians like Adrian Wilson insist that there is no real distinction between the ‘biological’ and the ‘social’, since both are human constructs.33 It is unlikely that Rosenberg intended to invest these labels with any essential meaning, however. Rosenberg is also right to suggest that certain types of disease – in so far as they can be identified retrospectively – have produced characteristic social ‘responses’, as the following chapters attest. Where the metaphor of ‘framing’ fails somewhat is in capturing the dynamic nature of knowledge; it suggests that nature is simply viewed, rather than actively shaped, by scientific investigators, as Latour reminds us in his study of Pasteur’s laboratory.

Wilson’s target is not only Rosenberg’s notion of ‘framing’, but the ‘naturalist-realist’ approach more generally – an approach that seeks to establish the ‘true’ identity of diseases in the past. Among the ‘neo-realists’ considered by Wilson are many distinguished historians, such as Alfred W. Crosby and William H. McNeill, whose work will be considered at more length in the following chapters.34 But Wilson alerts us to a problem that deserves attention at the outset: the problem of retrospective diagnosis. The extent to which retrospective diagnosis is valid is hotly debated among historians. There are those (we might call them ‘historicists’) who see little point in attempting to identify and classify the afflictions of the past, but many still feel that the enterprise is justified if pursued with caution. In reality, both historicism and qualified realism can be fruitful methodologies, depending on which questions the historian chooses to ask. Wilson’s invitation to study ideas about disease rather than diseases, alerts us to the different ways in which disease was conceived over time and across cultures, and it avoids the common assumption that a modern disease category such as ‘plague’ or ‘cholera’ necessarily referred to the same thing in the past. The history of diseases, on the other hand, can help us to reconstruct life in past times, to explain the rise and fall of civilizations, to identify social differences in the incidence of ill health, and to assess the consequences of economic and environmental change.

Disease can only be fully understood as a historical phenomenon if we attempt both forms of inquiry. It is important to see the past as far as possible in its own terms, while realizing that we can never entirely divest ourselves of the present. Nor is there any reason why we should do so. Providing we do not distort the views of historical actors, there is much to be gained from using modern knowledge about disease in order to elucidate the past. After all, if we are to understand the ways in which people made sense of disease, it is useful to know what they were confronted with. The evidence available to us necessarily imposes limitations on our ability to re-create the past and to identify any disease with certainty; but it may be possible within certain bounds of probability. Reading textual sources to identify diseases is fraught with problems, but this is no reason to give up altogether: some diseases, such as plague and yellow fever, have symptoms that are distinctive, and may also display epidemiological characteristics that enable them to be distinguished from one another. In some cases, it is also possible to correlate textual evidence with that from paleopathology, which has the capacity to demonstrate the existence of diseases such as leprosy and syphilis by examining human remains.35 Our motto might therefore be, ‘Let a thousand flowers bloom’.

This book began life as a history of disease from ancient times, rather than a history of disease in what I have perhaps foolishly called the ‘modern world’. It soon became apparent that my original plan was impossible within the word limit and that it had to be scaled down in some way. I felt uncomfortable with a project restricted to ‘the West’, as the European colonies have always been one of my main interests, so limiting the time-scale was the only realistic option. Though problematic, the concept of modernity offered a way of imposing some kind of unity on an otherwise diverse range of sources, while enabling me to cover a broad geographical range. The scope of this book widens gradually, as modern forms of society emerged or were imposed around the globe. I have decided to opt for a more or less chronological structure, using case studies to explore broader issues, while at the same time providing enough detail to demonstrate their complexity, together with the richness of the subject-matter.

One obvious difficulty in such an approach, and in writing any synthetic work of history, is deciding what to include and what to exclude. Although I thought I had a fairly good command of the literature before I began, I was surprised by just how much had been written on disease and by the extent of my ignorance. Writing Disease and the Modern World has therefore been a great learning experience, but, unfortunately, there was not sufficient space to discuss much of what I read. The original manuscript was considerably longer than the final version, and that, too, omitted a good deal. Readers with some knowledge of the field may be surprised or disappointed to find that some subject dear to them has not been covered. I can only say that I am aware of these limitations, and offer my apologies in advance. I have chosen to concentrate on the social, economic, demographic and intellectual aspects of the history of disease, and specifically on infectious diseases, chiefly because the literature in these areas allowed me to explore more easily the theme of modernity, and particularly the rise of the modern state, which is closely related to the threat of disease. In so doing, I have highlighted some areas that have not been given sufficient attention in the existing literature – such as the relationship between war and disease – while saying rather less about others, like cultural representations.

As many of the terms used in the book are rather technical, I have provided an extensive glossary. For ease of reference, I have also provided full publication details for each of the works referred to on the first occasion they are cited in each chapter. It was not possible to provide a full bibliography, but a select bibliography of key works is located at the end of the book.

Notes

1 Agnes Heller, A Theory of Modernity (Blackwell, Oxford, 1999), p. 52.

2 Max Weber, Economy and Society, ed. G. Roth and C. Wittich (University of California Press, Berkeley, 1978[1922]), vol. 1, chs 3 and 7; vol. 2, ch. 11; idem, The Protestant Ethic and the Spirit of Capitalism, tr. T. Parsons (HarperCollins Academic, London, 1991[1930]).

3 Heller, Theory of Modernity, pp. 1–18.

4 Fernand Braudel, Capitalism and Material Life 1400–1800 (Fontana, London, 1979), p. 1.

5 Recent surveys include Philip D. Curtin, The World and the West: The European Challenge and the Overseas Response in the Age of Empire (Cambridge University Press, Cambridge, 2000); A. G. Hopkins (ed.), Globalization in World History (Pimlico, London, 2002).

6 Immanuel Wallerstein, The Modern World System (3 vols, Academic Press, New York, 1974–80).

7 The classic studies are Paul Baran, The Political Economy of Growth (Penguin, London, 1973[1957]); A. G. Frank, ‘The Development of Underdevelopment’, Monthly Review, 24 (1966), pp. 17–31. A good recent study is Robert Biel, The New Imperialism: Crisis and Contradiction in North/South Relations (Zed Books, London, 2000).

8 See John V. Pickstone, Ways of Knowing: A New History of Science, Technology and Medicine (Manchester University Press, Manchester, 2000).

9 David Healy, The Antidepressant Era (Harvard University Press, Cambridge, Mass., and London, 1997).

10 A useful introduction is provided in Andrew Cunningham and Bridie Andrews (eds), Western Medicine as Contested Knowledge (Manchester University Press, Manchester, 1997).

11 See Arthur A. Caplan, ‘The Concepts of Health, Illness and Disease’, in Companion Encyclopedia of the History of Medicine, ed. W. F. Bynum and R. Porter (Routledge, London, 1993), pp. 233–48; Robert P. Hudson, ‘Concepts of Disease in the West’, in The Cambridge World History of Human Disease, ed. K. Kiple (Cambridge University Press, Cambridge, 1993), pp. 45–52.

12 Christopher Boorse, ‘On the Distinction between Disease and Illness’, Philosophy and Public Affairs, 5 (1975), pp. 49–68; idem, ‘What a Theory of Mental Health Should Be’, Philosophy of Science, 44 (1976), pp. 542–73.

13 A. L. Caplan, H. T. Engelhardt Jr and J. M. McCartney (eds), Concepts of Health and Illness: Interdisciplinary Perspectives (Addison-Wesley, Reading, Mass., 1981); C. Currer and M. Stacey (eds), Concepts of Health and Illness and Disease: A Comparative Perspective (Berg, Leamington Spa, 1986).

14 P. Atkinson, Medical Talk and Medical Work: The Liturgy of the Clinic (Sage, London, 1995). See also Robert Dingwall, Aspects of Illness (Martin Robertson, London, 1976), ch. 6.

15 Ludwik Fleck, The Genesis and Development of a Scientific Fact, trs. F. Bradley and T. J. Trenn, ed. T. J. Trenn and R. K. Merton (University of Chicago Press, Chicago, 1979).

16 Owsei Temkin, The Falling Sickness: A History of Epilepsy from the Greeks to the Beginnings of Modern Neurology (Johns Hopkins University Press, Baltimore, 1945).

17 e.g. F. A. Hirst, The Conquest of Plague: A Study of the Evolution of Epidemiology (Oxford University Press, Oxford, 1953).

18 The classic early studies include Barry Barnes, Scientific Knowledge and Sociological Theory (Routledge and Kegan Paul, London, 1974); idem, Interests and the Growth of Knowledge (Routledge and Kegan Paul, London, 1977); Barry Barnes and Steven Shapin (eds), Natural Order: Historical Studies of Scientific Culture (Cambridge University Press, Cambridge, 1979).

19 Karl Figlio, ‘Chlorosis and Chronic Disease in Nineteenth-Century Britain: The Social Construction of Somatic Illness in a Capitalist Society’, Social History, 3 (1978), pp. 167–97.

20 The new agenda was most clearly expressed in P. Wright and A. Treacher (eds), The Problem of Medical Knowledge (Edinburgh University Press, Edinburgh, 1982). A classic study in this vein is Christopher Lawrence, ‘“Definite and Material”: Coronary Thrombosis and Cardiologists in the 1920s’, in C. E. Rosenberg and J. Golden (eds), Framing Disease: Studies in Cultural History (Rutgers University Press, New Brunswick, NJ, 1992), pp. 51–82.

21 François Delaporte, Disease and Civilization: The Cholera in Paris, 1832, trs. A. Goldhammer (MIT Press, Cambridge, Mass., and London, 1986), p. 6.

22 See, e.g., Christopher Lawrence, ‘Disciplining Disease: Scurvy, the Navy, and Imperial Expansion, 1750–1825’, in Visions of Empire: Voyages, Botany, and Representations of Nature, ed. D. P. Miller and P. H. Reill (Cambridge University Press, Cambridge, 1998), pp. 80–106; Christopher Hamlin, Public Health and Social Justice in the Age of Chadwick: Britain, 1800–1854 (Cambridge University Press, Cambridge, 1998).

23 Alison Bashford and Claire Hooker, ‘Introduction: Contagion, Modernity and Postmodernity’, in Contagion: Historical and Cultural Studies, ed. A. Bashford and C. Hooker (Routledge, London, 2001), p. 7.

24 Mary Douglas, Purity and Danger: An Analysis of the Concepts of Pollution and Taboo (Routledge, London, 1991[1966]), p. 35. Some of these ideas are explored further in Douglas’s Natural Symbols: Explorations in Cosmology (Penguin, Harmondsworth, 1978[1970]).

25 See Alison Bashford, Purity and Pollution: Gender, Embodiment and Victorian Medicine (Macmillan, London, 2000).

26 Ludmilla Jordanova, ‘The Social Construction of Medical Knowledge’, Social History of Medicine, 8 (1995), pp. 361–82.

27 Bruno Latour, The Pasteurization of France (Harvard University Press, Cambridge, Mass., 1988), p. 159. See also Latour’s ‘Give me a Laboratory and I will Raise the World’, in Science Observed: Perspectives on the Social Study of Science, ed. K. Knorr-Cetina and M. Mulkay (Sage, London, 1983), pp. 141–70.

28 Simon Schaffer, ‘The Eighteenth Brumaire of Bruno Latour’, Studies in History and Philosophy of Science, 22 (1991), pp. 174–92.

29 See Steve Sturdy, ‘The Germs of a New Enlightenment’, Studies in the History and Philosophy of Science, 22 (1991), pp. 163–73.

30 See Jan Golinski, Making Natural Knowledge: Constructivism and the History of Science (Cambridge University Press, New York and Cambridge, 1998); Michael Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain, 1865–1900 (Cambridge University Press, Cambridge and New York, 2000), pp. 12–13.

31 Charles Rosenberg, ‘Introduction – Framing Disease: Illness, Society and History’, in Framing Disease, ed. Rosenberg and Golden, pp. xii–xxvi. This essay is reprinted in Charles Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge University Press, New York and Cambridge, 1992), pp. 305–18. All citations below refer to the latter.

32 Rosenberg, ‘Framing Disease’, p. 307.

33 Adrian Wilson, ‘On the History of Disease-Concepts: The Case of Pleurisy’, History of Science, 38 (2000), p. 282.

34 See Alfred W. Crosby, The Columbian Exchange: Biological and Cultural Consequences of 1492 (Greenwood Press, Westport, Conn., 1972); idem, Ecological Imperialism: The Biological Expansion of Europe, 900–1900 (Cambridge University Press, New York, 1986), William H. McNeill, Plagues and Peoples (Anchor Press, Doubleday, Garden City, NY, 1976). See notes to ch. 5 for a fuller set of references.

35 See Keith Manchester, The Archaeology of Disease (University of Bradford Press, Bradford, 1983); Charles L. Greenblatt (ed.), Digging for Pathogens: Ancient Emerging Diseases – Their Evolutionary, Anthropological and Archaeological Context (Balaban Publishers, Rehovot, 1998).

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