The Black Death

Plague Doctors and Their Practices

The physicians, surgeons, and healers who treated plague patients during the Black Death worked within a medical tradition that was learned, systematic, and fundamentally inadequate to the task they faced. Their efforts — ranging from the learned prescriptions of university-trained physicians to the desperate improvisations of village healers — provide a window into the practice of medicine in the fourteenth century and illuminate the gap between medical theory and the reality of epidemic disease.

The Hierarchy of Healers

Medieval medicine was organised in a strict hierarchy. At the top were the university-trained physicians (medici), who held degrees in medicine and practised diagnosis and prescription based on the authoritative texts of Galen, Avicenna, and Hippocrates. Below them were the surgeons (chirurgici), who were trained through apprenticeship and performed operations, set bones, and treated wounds. Below the surgeons were the barber-surgeons, who performed bloodletting, tooth extraction, and other minor procedures. At the bottom were the apothecaries, who prepared and dispensed medicines, and the various unlicensed healers — midwives, herbalists, and folk practitioners — who served the majority of the population.

During the Black Death, this hierarchy was disrupted. Many university-trained physicians fled the plague-stricken cities, following their own advice to avoid infected areas. Those who remained were overwhelmed by the scale of the catastrophe. The distinction between learned physicians and unlicensed healers blurred as desperate patients turned to anyone who offered treatment, regardless of their qualifications.

The Plague Doctor’s Appearance

The iconic image of the plague doctor — a figure in a long waxed coat, wide-brimmed hat, and a beaked mask stuffed with aromatic herbs — is largely a product of the seventeenth century, not the fourteenth. The beaked mask was designed by the French physician Charles de Lorme in 1619, and the full costume was adopted by municipal plague doctors during the later outbreaks of the seventeenth century. During the Black Death itself, physicians wore ordinary clothing, though some may have carried posies of herbs or aromatic substances to ward off miasma.

The development of the plague doctor’s costume reflects the gradual evolution of public health measures over the centuries following the Black Death. The waxed coat was intended to prevent the adherence of pestilential particles, the beak was filled with substances believed to purify the air, and the wide-brimmed hat identified the wearer as a physician. The costume was, in essence, a primitive form of personal protective equipment, designed according to the miasma theory of disease transmission.

Diagnosis of the Plague

Physicians diagnosed plague through the observation of characteristic symptoms. The appearance of buboes — painful, egg-sized swellings in the groin, armpit, or neck — was the most reliable sign of bubonic plague. The physician Guy de Chauliac, who treated patients in Avignon during the epidemic of 1348, described the disease in two phases:

“The first was during two months with continuous fever and spitting of blood, and the sick died within three days. The second was during the rest of the time, also with continuous fever, and with apostemes [buboes] and carbuncles in the armpits and groin, and the sick died within five days.”

This description corresponds to the modern distinction between pneumonic plague (the first phase, with coughing of blood and rapid death) and bubonic plague (the second phase, with buboes and a somewhat longer course). De Chauliac’s clinical observation was remarkably accurate, even though his understanding of the disease’s cause was based on miasma theory and astrological conjunctions.

Other symptoms noted by contemporary physicians included high fever, headache, nausea, delirium, dark patches on the skin (suggesting septicemic plague), and a characteristic odour that was said to emanate from plague patients. The speed of the disease’s progression — from the first symptoms to death in as little as one to five days — was one of its most terrifying features and one that left physicians with little time for treatment.

Standard Treatments

The standard medical treatments for plague were based on the principles of humoral medicine. Bloodletting was the most common intervention, performed to reduce the excess of corrupt blood that was believed to cause the disease. The procedure was typically performed on the vein nearest to the affected bubo, in the hope of drawing the corrupt humour away from the site of infection. In practice, bloodletting weakened patients who were already debilitated by fever and infection, and it may have increased mortality.

The lancing of buboes was widely practised. Physicians incised the swollen lymph nodes to drain the pus and corrupt matter within, sometimes applying poultices of herbs, onions, or dried figs to draw out the infection. This procedure, while painful and risky (it could introduce secondary infections), may have provided some relief in individual cases by reducing the pressure within the bubo and allowing the body’s immune system to fight the infection more effectively.

Purging — the administration of emetics and laxatives to expel corrupt humours from the digestive system — was another standard treatment. The resulting dehydration and weakness were counterproductive, but the logic of the treatment was consistent with humoral theory.

Medicines and Compounds

The pharmacopoeia of plague medicines was vast and varied. Theriac, a complex compound medicine containing up to sixty-four ingredients (including opium, viper flesh, honey, and various herbs and spices), was considered the most powerful antidote to poison and was widely prescribed for plague. Armenian bole, a red clay from the Caucasus, was believed to absorb toxins and was applied to buboes or taken internally. Rose water, vinegar, and various herbal preparations were used to cool the patient and counteract the heat of the fever.

Precious stones and metals were sometimes employed. Emeralds, sapphires, and pearls were ground into powder and administered in drinks, based on the belief that their cold, dry qualities could counteract the hot, moist corruption of the plague. Gold was similarly used, though its expense limited its availability to the wealthy.

The use of these substances reflected the medieval belief in the medicinal properties of natural objects, which were classified according to their qualities (hot, cold, moist, dry) and their correspondences with celestial bodies. The logic was internally consistent, even though the substances themselves had no effect on the bacterial infection.

The Role of Religion and Magic

Many patients and healers turned to religious and magical remedies when medical treatments proved ineffective. Prayers, processions, and the veneration of saints’ relics were widely practised. Amulets inscribed with religious texts or astrological symbols were worn to ward off the disease. Exorcisms were performed on the sick, based on the belief that the plague might be caused by demonic possession.

The Church promoted the idea that the plague was a punishment from God, and that repentance, confession, and prayer were the most effective remedies. This view was not necessarily incompatible with medical treatment — many physicians were clerics, and the two approaches were often used in combination — but it placed limits on the perceived efficacy of medicine. If God had sent the plague, then only God could take it away, and the physician’s role was limited to alleviating suffering and preparing the patient for death.

Flight as Medicine

The most effective “treatment” for plague was flight from infected areas. The ancient medical maxim cito, longe, tarde — “flee quickly, go far, return slowly” — was widely cited during the Black Death, and many who could afford to do so left the cities for the countryside. This practice, while self-interested, was medically rational: removing oneself from an environment where rats and fleas were concentrated reduced the risk of infection.

However, flight was available only to the wealthy. The poor, who could not afford to abandon their homes and livelihoods, bore the brunt of the epidemic. The social inequality of plague mortality was noted by contemporary observers, including Boccaccio, who described the different responses of the rich (who fled), the moderate (who stayed but isolated themselves), and the reckless (who abandoned themselves to pleasure).

Municipal Plague Doctors

Some Italian city-states employed municipal plague doctors — physicians hired by the government to treat plague patients, regardless of their ability to pay. These doctors, who were often foreign physicians seeking employment rather than established local practitioners, were given special privileges and protections in return for their service. They were permitted to perform autopsies (normally restricted), were provided with housing and a salary, and were sometimes given the authority to enforce quarantine regulations.

The experience of municipal plague doctors contributed to the development of a more empirical approach to epidemic disease. Working directly with large numbers of patients, they accumulated clinical observations that sometimes challenged the authoritative texts. Their reports and treatises formed an important body of primary source material for the study of the plague.