September 19, 2020
A Plague Doctor by Carlo M. Cipolla. Excerpt from the book The Medieval City (1977)
This is an excerpt from the book The Medieval City, published in 1977. Chapter 4, “A Plague Doctor” by Carlo M. Cipolla (1922-2000).
A plague doctor
The Medieval and Renaissance city was affiicted with a problem which was essentially ecological in nature, namely a violent disequilibrium between the density of the population and the prevailing levels of hygiene and public health. The dire result of this disequilibrium was the recurrence of epidemics, mostly of bubonic plague, which at closely spaced intervals wiped out a large portion of the population. Ever since the outbreak of the great pandemic of 1347 – 1351 people recognized the infectious nature of plague, but because they were totally ignorant of the sequence rat – rat’s flea – man they overrated the possibility of man to man infection.
Thus it was not easy in time of epidemic to find doctors willing to treat plague patients. On the other hand, if the plague were so highly contagious, a doctor visiting a patient – it was argued – would not only easily contract the infection but would also carry it to other people or to patients suffering from other ailments.
The solution to this double-edged problem was found with the institution of the community plague doctors. These were physicians or surgeons, especially hired by an infected town or village in time of an epidemic, who were responsible for the treatment of the plague patients only and had to refrain from intercourse with the rest of the population.
Their job was not only particularly dangerous but also very unpleasant because the plague doctor was quarantined, so to speak, for the entire period of the epidemic and some til the thereafter.
Those who applied for such positions were normally either second rate doctors who had not been particularly successful in their practice or young doctors trying to establish themselves.
Texts of agreements between town administrations and plague doctors are not difficult to find in the archives and some have been published. Although they inform us about the terms eventually agreed upon by the parties involved, the cold and detached juridical prose of the notaries hardly reveals the bargaining which always preceded the final settlements. The bargaining was often hard.
Real case of a plague doctor: Dr. Maletto
On May 10, 1630, the town council of Torino considered the conditions requested by one Dr. Maletto to serve as a plague doctor. After some discussion the council instructed its representatives “to deal promptly with Dr. Maletto. They should try to reduce his pretenses and extract the best possible deal for this community but they ought to be careful not to lose the opportunity of hiring Dr. Maletto because it would be difficult to find a substitute at the same salary.”
In the Communal Archive at Pavia (Lombardy) there is the original draft of an agreement reached between the community and a plague doctor. The document is of special interest because it shows a series of corrections and additions to the original text that are suggestive of the bargaining that took place.
Real case of a plague doctor: Giovanni de Ventura
The document is dated May 6, 1479, and it contains the “conditions agreed upon between the magnificent Community of Pavia and the doctor of medicine Giovanni de Ventura in order to treat the patients suffering from the plague.”
The first clause deals with the salary. The community promised to pay to the doctor a monthly salary of 30 florins, which, as we shall see, had to be net of living expenses.
The second clause originally provided that the community would pay the salary two months in advance. This amounted to an interest free deposit equivalent to two months’ salary in favor of the doctor. However, in the bargaining that followed, the clause was modified, and the town’s representatives managed to cut the advance to one month’s salary.
Obviously the doctor had some doubts about the solvency of the community, and he was not satisfied with the advance payment. He wanted more guarantees, and the third clause of the contract stipulates that the community had to give the doctor an adequate pledge for the payment of his salary. On this point there seems to have been no further discussion.
A fourth clause also raised no difficulties. It was common practice in the hiring of an immigrant community doctor, whether plague doctor or not, that the community would provide him with a convenient house free of charge or at a reduced rent. In this particular case, the community of Pavia promised to provide Dr. Ventura with “an adequate house in an adequate location,” completely furnished, at the community’s expense. The clause suggests that Dr. Ventura had not been living in Pavia.
Disagreement must have flared up again on the fifth clause. Originally it had been stipulated that the city administration would continue to pay the doctor his salary for two months after the termination of his employment. Later on, however, the town’s representatives backed out, and in the subsequent bargaining, as in the matter of the advance, they managed to reduce the extra pay to one month’s salary.
In both clause two and clause five, the final text is less favorable to Giovanni Ventura than the original draft. Were the administrators beginning to feel some doubts about the quality of the doctor’s services? Or, having brought the doctor to the verge of acceptance, did they feel that toughness might extract from him an even better deal? We shall never know, but the modifications to the original text of clauses six and seven seem to favor the first hypothesis.
The sixth clause originally specified the duties of the doctor, emphasizing the limits of his obligation. It stipulated that “the said master Giovanni shall not be bound nor held under obligation except only in attending the plague patients.” Later on, however, the town’s representatives felt that they needed a better guarantee of a satisfactory performance and pressed for an addition which specified the doctor’s duties in more positive terms: “namely, the doctor must treat all patients and visit infected places as it shall be found to be necessary.”
With the seventh, clause the town’s administration committed itself to give a free grant of Pavian citizenship to the doctor in appreciation for his good services. But again, at the time of the final draft, it was felt necessary to qualify the original text by the conditioning clause “according to how he shall behave himself.”
What kind of man was Master Giovanni Ventura? We have no information on him and all we can do is to speculate on the limited basis of the agreement he made with the town of Pavia during a time of a social tragedy. He was ready to risk his life for some 30 florins a month, and it is doubtful whether he assumed this risk for purely humanitarian reasons.
He was obviously anxious to obtain the citizenship of Pavia. One is tempted to think of him as an uprooted adventurer. But I doubt that that was the case. More likely he was an obscure doctor from the countryside, and the fact that he was normally addressed as “master” clearly shows that he was of humble social standing. There were in the villages young men who, thanks to scholarships or to the economic sacrifices of their parents or to both, managed to obtain a university degree. But it was not easy for them to practice in the cities because the city doctors did not welcome competition, and they therefore resisted the immigration of more doctors. On the other hand, as the memoirs of Jerome Cardano testify, toward the end of the fifteenth century a physician did not fare well in the countryside where peasants often had recourse to barbers and quacks. The dream of a young country doctor was to be admitted to the city. Perhaps Dr. Ventura was such a one, and when the plague hit the city, he played his version of Russian roulette: if all went well, he would have obtained the citizenship of Pavia, thus establishing there both his residence and practice.
Did Dr. Ventura have a family? In all likelihood he had neither wife nor children; otherwise their presence would have been mentioned in the clause referring to the house that the community had to provide for him. Yet Dr. Ventura must have had relatives in mind when he made the stipulations in the agreement. The chances of survival of a plague doctor during an epidemic were not high, and in clause eight, with obvious reference to the advance payment granted by clause two, Dr. Ventura obtained the promise that “in the event – may God forbid it – that the said Master Giovanni should die in the exercise of these duties, that then and in that case his heirs should not be required to make restitution of any part of his salary that might remain unearned.” Was he thinking of his parents?
The institution of the community doctor in the Italian cities dated back to at least the end of the twelfth century. The idea behind the institution was to make available free medical treatment and care for the poor. The community plague doctor was but a special kind of community doctor and clause nine is similar to the analogous clauses that one finds in all agreements relating to the hiring of community doctors: “the said Master Giovanni shall not be able to ask a fee from anyone, unless the plague victim himself or his relatives shall freely offer it.”
A plague epidemic was not only a human tragedy for a city; it was also an economic disaster. All too often, enormously swollen expenditures on public health measures were accompanied by drastic diminution of revenues, and all this meant bankruptcy for the frail public finances.
Reading the agreement, one has the impression that Master Giovanni was more worried about the solvency of the city than about his chances of survival. With clause two he had obtained an advance payment. With clause three he had obtained from the city a special pledge to guarantee his salary. With clause ten he obtained that “whenever and however it of this kind the city may be brought so low that Master Giovanni cannot have his wage nor the things necessary to his existence, that then and in that case Master Giovanni may be released from his obligation without any penalty.”
By the end of the fifteenth century the gulf between physicians and barber-surgeons was widening in Italy; the physicians were more and more regarded as upper class while the barber-surgeons were increasingly considered part of the lower orders. By the end of the sixteenth century a physician was no longer addressed as “master”; that title being normally reserved to the barber-surgeons. In 1479, things had not yet gone so far, although even then it would have been unusual for a high-ranking, distinguished physician to be addressed with the title of “master.” Dr. Ventura was obviously neither distinguished nor high-ranking. However, he was a physician and not a barber-surgeon, because clause eleven stipulates that “the Community is under obligation to maintain a barber who should be at least adequate and capable.” The reason for the clause is obvious: a main task in the treatment of plague patients was lancing their suppurating bubos and the operation was normally performed by a barber-surgeon and not by a physician.
A city infected with plague was quarantined by all other places; trade and communications were halted, victuals became scarce and difficult and expensive to obtain. Many of those who were spared by the plague could hardly escape starvation. Dr. Ventura protected himself against these unpleasant events with clause twelve, which stipulates that “the Community has and is under the obligation to provide said Master Giovanni with all and everything which is necessary for his life, paying and exbursing the money therefore.” Master Bernardino di Francesco Rinaldi obtained a similar clause when he was hired as plague doctor by the city of Volterra in 1527.
With clause four Dr. Ventura had already secured for himself free housing facilities: clause eleven took care of all other living expenditures. Thus the 30 florins of the monthly salary could be left untouched and put aside. When one’s life is at stake, it is hard to decide whether pecuniary compensation is adequate or not. As we shall see below, however, by the standards of the time, the financial terms extracted by Dr. Ventura were reasonably adequate. But he kept worrying about the solvency of the community. He had already obtained the promise of an advance payment (clause two). He wanted a special pledge to guarantee his salary (clause three). He had made certain that in case of insolvency he would be released of his obligation (clause ten). But these guarantees were seemingly not enough to set his mind at rest. In a final assault on the problem he extracted clause thirteen, which stipulates that “however the community would not observe the previously agreed conditions, either partially or totally, then and in that case it would be possible to said Master Giovanni to be totally free from any engagement, notwithstanding the previous clauses or others to be made.” Clause thirteen practically repeats what was already established by clause ten.
What the town’s administrators thought of this obsession of Dr. Ventura and of his being more concerned with the possible insolvency of the Community than with the probability of his catching the plague we shall never know. We know, though, that after they had accepted clause thirteen and had recognized the doctor’s right Ito leave the job under the aforesaid conditions, the administrators pressed to have this addition inserted: “that the doctor should notify the community at least ten days in advance so that the Community would be in the condition to provide (for a substitute).”
While Giovanni could not take his mind off the community’s possible insolvency, the town’s administrators kept worrying about the kind of service that the doctor would provide to the patients. The minds of the two parties were following different logics and as the doctor persistently returned to his own point, the administrators felt that they had to reiterate their own. They had already managed to add to clause six the condition that “the doctor must treat all patients and visit infected places as it shall be found to be necessary.”
They had also succeeded in emphasizing that the grant of citizenship would be dependent on “how shall he behave himself” (addition to clause seven). But they were still uneasy. They therefore requested the insertion of clause fourteen, which stipulates that “said Master Giovanni would have and should be obliged to do his best and visit the plague patients, twice, or three times or more times per day, as it will be found to be necessary.”
The town administrators were understandably concerned with the capacity of the doctor to resist the assault of the infection and to deliver his services. This concern was not motivated by pure humanitarianism. Clause fifteen stipulates that “in the case – may God forbid it – that the said Master Giovanni would fall ill, and could not perform his office, that then and in such case he should receive a salary only for the time of effective service.”
The last clause stipulated that “said Master Giovanni will not be allowed a man especially designated by the Community.” The explanation offered is that Dr. Ventura when accompanied by the deputy would be “identified as the doctor appointed to that office,” but the real reason behind the clause was to ensure that the doctor would not intermingle with other people. The deputy’s function was to monitor Giovanni’s movements.
Real case of a plague doctor: Stefano Mezzettino
In Prato, in December 1527, the community made an inquiry on the behavior of the local plague doctor Stefano Mezzettino. It was noticed that, according to the rules, “when the community plague doctors move around they always have to be accompanied by a custodian especially appointed, but said Master Stefano went to treat a patient in Pinzidemoli and went there alone, without the custodian, with great danger for all concerned.” He was reprimanded and fined. A plague doctor was regarded as a contact and all contacts had to live in isolation.
From the remarks I have made on some of the clauses, it will be apparent that the agreement made between Dr. Ventura and the city of Pavia was not dissimilar from analogous agreements made in other cities. One has, indeed, the distinct impression that by the last quarter of the fifteenth century a standard formula had evolved. This formula was adopted, with minor variations, in places as different as Turin in Piedmont, Pavia in Lombardy, and Volterra and Prato in Tuscany. The pecuniary reward, however, varied considerably from place to place, largely depending on the quality and prestige of the doctor, the availability of substitutes, the severity of the epidemic, and the urgency of the town’s needs. Dr. Ventura, we have seen, was granted 30 florins per month, the free use of a house, and his living expenses.
The salary of a plague doctor
The florins mentioned in the contract were units of account. Thirty such florins corresponded to 11 1/2 gold florins and therefore to approximately 40 grams of pure gold. What this meant in terms of purchasing power is difficult to say because the price structure of those days was totally different from the price structure of today. Books of medicine were then valued in Lombardy between 5 and 13 florins each, with many having the value of 6.5 florins. Thus the 30 florins that Dr. Ventura received each month hardly bought five books of medicine. But manuscripts cannot be compared with the printed books of today, and few doctors owned more than some dozen books. Compared to other salaries, the salary of Dr. Ventura was not at all bad. A skilled worker, if he managed to be employed 200 days a year – which was virtually impossible – hardly made 60 florins in a year. The accountant of the community made 84 florins a year. The mayor of the city made 540 florins. At the university here were two or three famous professors who earned more than 1,000 florins per year, but 75 percent of the lecturers earned less than 200 florins per year. A contemporary living in a developed country may think that 40 grams of gold per month do not represent an exceptionally attractive salary. But in fifteenth century Europe gold was a scarcer commodity. Life was often brutish and short, and death was a more familiar event. Our story proves that a monthly salary of 40 grams of gold plus living expenses was high enough to attract a doctor to a job which bordered on suicide.
