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Carmichael Health Florentine

Carmichael Health Florentine - Health Status of Florentines...

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Unformatted text preview: Health Status of Florentines an only to die of debilitating chronic illness. Unlike the various acute infections, exposure to these kinds of diseases among urban Italians in the Renaissance did not depend on wealth and social class. This paper will explore, in a very preliminary fashion, the kinds of ordinary illness and death experiences that were typical in Renais— sance Italian cities, drawing from soma reconstructions of family medical history, from dinical narratives of illness and death written in the late fifteenth century, from fiscal records reflecting the average burden of illness carried by households of this period, and from causes of death in ordinary nonplague years. It is not always possible to find Florentine records that show the typical patterns of sickness, so, assuming that urban morbidity and mortality were uniform across northern ltaly, l will utilize materials from other areas in my assass- ment of the Florentine situation. Retrospective diagnosis is very difficult and uncertain, even with good medical records, but the evidence presented in the following pages strongly points to the role of tuberculosis as the major killer among urban populations in northern and central Italy in the Renais- sance. Social and medical historians usually associate this chronic disease with the early phases of the industrial revolution, possibly because during that time physicians everywhere in Europe began to describe its ravages. But two hundred years before John Bunyan labeled this disease ”captain of all these men of Death,” and two hundred years before John Morton provided the first classic medical description of acute and chronic pulmonary tuberculosis, the disease was endemic in the growing, crowded cities of Italy,I and for both rich and poor exposure to this common pathogen seems to have in- fluenced all subsequent experience of lllnEss and death. Starting from a detailed case study of the last illness of Lorenzo di Piero di Lorenzo de’ Medici, duke of Urbino, I will outline the history The Health Status of Florentines in the Fifteenth Century 'l' Ann G. Carmichael Five hundred years ago urban Florentines had to expect that at least one—third of those born would die in infancy and that no genera— tion of survivors would reach adulthood without experiencing in some way the relentless cycles of recurrent plague.1 Epidemics, domir nated by plague, occurred three times every two decades, sweeping into the grave defenseless babies and the chronically ill. High infant mortality and epidemic disease were essentially refractory to the best medical remedies of the day. The wealthy were. for the most part, able to escape plagues by leaving the city for safer countryside re— treats, and thus actual experience with the plague, including the powerful mentalité of fear its recurrences created, was bound to the expectation of a differential mortality between rich and poor.2 These violent, acute infections capture the imagination in our cena tury and have drawn the attention of contemporary scholars of medi- cal history. 0n the other hand, far less attention has been given to the background, nonplague illnesses of the Renaissance. It is difficult for recent generations, burdened with chronic rather than acute dis— eases, to realize that the ”ancien regime of disease,” as the preindus- trial past has been called recently, was not fully dominated by the Savage rapacity of acute pestilences and plagues.R The fact is, how- ever, that chronic illness and infection throughout the life course were decidedly a part of life five hundred years ago. With or without sick‘ ness many lived through the young and middle adult passages escap— ing plague, the sequelae of childbearing, and other acute infections, of his illness and briefly reconstruct a family history of the Medici that illustrates how tuberculosis could have been a common pathogen in the Renaissance. Lorenzo, the last direct male heir of Cosimo the Elder, died in Florence May 4, 1519, at the age of twenty—seven. He may have had other medical problems underlying his terminal illness-—consuming the last half-year of his life—but there is little reason to challenge the diagnosis of pulmonary tuberculosis that was made seventy-five 3:: Ann '5. Carmichael years ago by Andrea lE'Zorsini, drawing upon the minutely detailed records of both the secretary and the physician to the duke.E5 In the next few paragraphs I summarize the clinical course that led Corsini to this diagnosis. As early as 1515-115, when in his early hventies, the duke of Urbino suHeIEd leg ulcers and blisters described as "French boils” by one contemporary, but nonmedicai, observer. From this point on he car— ried the diagnosis of the French disease, or syphilis, justly, some said, because of his sfrerinto libertinaggio. The death of his wife, Madda- lena Tour d’Auvergne, shortly after the birth of their only child, Catherine de’ Medici, was blamed on her innocent infection with the "new disease" of the sixteenth century.“ In March 151;, two years before his death, Lorenzo sustained a head wound in battle, and many physicians debated whether or not the skull had been "tainted" {articulate}. After several days a fever appeared, the sign they had all feared, and so Lorenzo’s skull was trepl'llned. During his long; oonvnlescence his uncle Giuliano died of tuberculosis, and Lorenzo returned to Florence from Urbino against medical advice in order to visit his mother, Alfonsina Orsini, during an acute episode of her chronic bouts with "bloody flux.” In September 151:? Lorenzo had to delay another journey because of a poorly healing abscess on one foot. In March 1513 he was well enough to proceed with wedding plans and left for France in May. In August he and his bride returned; within ten months both died. During the same period, after a year-long remission. Alfonsina’s health worsened, and she could no longer disguise her difficulty sleep- ing and her recurrent vomiting. Throughout the fall of 1513 she bats tied kidney and stomach pains, debility, fever, fatigue, and the flux. As two generations of Medici women before her, she abandoned hope that the physicians' purges and emetics would help and left for the mineral baths of Volterra.“ Despite bland foods and mineral water therapy, her bleeding, blood-tinged vomitus, and anorexia continued through the winter. In November the duke himself fell gravely ill, so little attention could be paid to his mother’s suffering. Lorenzo’s last illness began with chills, fever, and headache, treated, as was usual, with purges.“ Fever, profuse sweating, and abdominal pains followed—the exacerbations usually at night—and so the physi— cians withdrew six ounces of blood, which they thought to be of "a Health Status of florentines 31 bad quality."m Purged again, moderate diarrhea EDIlDWEIl, along with understandable difficulty sleeping. Syrup of poppies helped, along with other tonics. In mid-December, after a brief remission, the fever chills, and vomiting and diarrhea returned, so his doctors tried mea: sures to open his pores, allowing another exit for bad or corrupted humors. After a remission there began abdominal pains, night sweats and fever. Sometimes the fever was described as putrid, sometimed choleric, sometimes double tertain, melancholic, or hectic. As the wmter wore on, joint pains, debility, and anorexia added to Lorenzo’s miseries, despite gentler, dietary treatment with chicken broths and syrups.‘1 By April 21 a reform, slightly productive of sputum, became the focus of medical efforts. The physicians indeed declared that catarrhal phlegm" was the efficient cause of his death on May a.- the failure to bring up the phlegm had "suffocated his heart.”12 H'hether or not Lorenzo ever had had the ”French boils” of syphilis Corsini noted that the duke was never treated for diis disease during his final illness. Nor is there any hint in this brief sketch that the oompheations of tertiary syphilis—commonly either neurological de— tenoration or sudden death from a dissecting aortic aneurysm—ended his life so early. Instead his clinical course was characterized by in~ fection {fever}, with intermittent gastrointestinal and pulmonary symp- toms over a six~month period, a course suggesting the diagnosis of tuberculosis. A likely explanation is that Lorenzo was first infected as a child, "seeded" the organism at many different sites, and then recovered. The infection then reactivated in his third decade.” Although we could devote considerably more attention to the de- scription of his illness, as Corsini has already done, it seems reasore able to assume that tuberculosis was the cause of Lorenzo's final illness. Certainly the treatment he was given confuses diagnosis of the underlying problems from our medical viewpoint, but there is other evidence for tuberculosis infection in the Medici family, mingled among other case studies of Medici illnesses and in letters betureen members of this family. Two deaths in the family were roughly contemporary with Loren— zo’s. Maddalena died twu weeks after delivery, one week before her husband’s death. Although she may have been, or become infected with either tuberculosis or syphilis [her pregnancy was sevdrai times threatened by fevers}, her death 1was nonetheless a classic course of 32 Am G. Carmichael puerperal sepsis or postpartum infection [usually streptococcal}, com- mencing two to three days after delivery. Lorenzo’s personal secretary noted that this was an illness common among puerperae in Florence that year.“ Lorenao’s mother, Alfonsina, died the following winter in February rfiao, two years ill with flusso. It is not unlikely that tuberculosis complicated her final illness, one Corsinl thought con- sistent with a diagnosis of uterine cancer. While neither of thesl:t two cases provides much additional evidence to my primary hypo esis, neither do they exclude coinfection with tuberculosis. . . . The familial illness usually associated with the hie-dict rs gout. Piero di Cosimo was nicknamed il Gottoso for hi: cr1pplmg arthrt: tides, nearly lifelong. Cosimo, his father, suffered a touch of gou d during the last decade of his life, and both father and son frequent: the hot mineral baths together. To a lesser extent both Lorenzo 1 Piero {ii Msgnifico} and his youngest son, Giuliano, duke of Hemours, suffered arthritic pains described as gout.“ . . . f Although gout could explain a four-generation Ifamlly h1stotpyto- joint pains, exclusively among men, once again comfertion :w1 u— berculosis is possible. Looking at the problem more closely 1s rgces sary because none of the skeletal remains of Cosimo the Elder, rero, Lorenzo, and Giuliano, duke of Nemours, provide evidence of gouty arthritic destruction of bone.” Piero il Goitoso suffered foot pgrns but never the classic swollen toe, and his first affirction was sal to have occurred in childhood, an exceedingly rare onset for fr“: ggut. Cosimo’s pains were described by his wife as ”a slight thing -— en; sufferers would so describe gout’s crises—and titan-years pf hisflgfi:n [ago—63} were punctuated by febrile episides: gout maidefl . attack of the plague," and, finally, a "cold. Moreover the . :1 males were not the only sufferers of arthritic PaJnE In this family. Hot mineral baths do not usually relieve gout, though they are enofi: mously beneficial to sufferers like Lucrezia Tornabuoni, P131} 5 it: I: who sought relief from "rheumatic gout” all her adult hfe. t1Tut :33 more, victims of gout usually survive to a much older age ‘an i ii Gottoso's gouty heirs. Lorenzo the Magnificent died 1n his eary forties "tormented by pain all over his body," and four of hlsfsiejv-ein children died in their late thirties [between 1516 and 1521}, of e 11 e ill esses notgout. . 1 Ill.lnforl-unateh_.r, the paleopathologists who exhumed the Medics Health Status of Florentinee 33 bones over thirty years ago failed to consider tuberculosis.” A con- current history supporting a diagnosis of tuberculosis exists, begin- ning with Giuliano di Piero di Cosimo, who died in his mid‘twenties during the Pazzi conspiracy. In 1463, at the age of eleven, Giuliano suffered from a chronic fever, much worse at night, throughout the summer. Pale and weak, exhausted by the evening fevers and the remedies applied, Giuliano nevertheless appeared basically healthy to his physicians and his mother once he was able to get rid of ”the phlegm which is in him.” His illness then abated.” These barebones details and the age of onset suggest the possibility of primary pul— monary tuberculosis. Four years after these events his mother, much sicker than usual with "rheumatic gout,“ went to the baths and “brought up much phlegm and nastiness which must have been there a long time.”21 Tu- berculous arthritis, a remote possibility in Lucrezia’s case, classically involves the hips, knees, elbmvs, shoulders, and small joints of the hands and feet, with pain on motion and usually some swelling. Of course, other arthritides, especially crippling rheumatoid arthritis, would also have been common. 1Lucrezia was willing to cope with ”bugs as big as capons” in the shabby accommodations at the baths. in order to obtain relief.” Lorenzo the Magnificent, whatever retrospective diagnosis one may favor in his own case, was married to a woman described consistently as a "consumptive" for the last ten years of her life, dying, as did most of their children, in her late thirties.“ Even with careful new attention to the medical genealogy of the Medici, however, this line of reasoning has rather obvious flaws: l have deliberately selected the tidbits of supporting information to show that many members of this prominent family suffered from some of the common, protean symptoms of tuberculosis infection. Because tuberculosis is surh a chronic, multisystern infection, diverse in clinical presEntation and often only a contributing cause of death, one could easily subsume the medical histories of many prominent individuals and families of the Renaissance under this diagnostic category, tidying up varied and tortured efforts at deciphering five-hundred—year-old patient records trapped in distinctively unmodern medical accounts.“ Uccam’s razor, applied to retrospective diagnosis, would favor the tuberculosis con— nection through this family medical history because it is the most 34 Ann G. Carmichael parsimonious explanation. Only Lorenzo, duke of Urbino, and his uncle Giuliano certainly died with the disease, so the more cautious conclusion at this stage would be that whatever the cause or causes of all these illnesses, suffering mediated the lives of the lv'ledici as much as it did the existence of their poorer. less advantaged con— ternporaries. TheSe difliculties with retrospective diagnosis are actually increased when we use a collection of patient records and autopsies of wealthy Florentines done during this period. Florence claims the ”father” of pathological anatomy, Antonio Benivieni, who dissected the corpses of his patients with apparently none of the stigmatization of that pro— DEdure that led Leonardo da Vinci to conduct anatomies in secret.” In a casebook devoted to the ”hidden and secret causes of illness" and death, Benivieni casually recorded his postmortem findings for pa- tients who died. Benivieni's brother posthumously gathered these notes to create the De Abdii—is Nonuullis cc Miranda‘s Morborum et Snood-strum Causls, In brief studies such as "death resulting from the stimulation of a cancerous ulcer,“ or “worms ejected," or “death due to intermittent fever.” Fifteen of the 111 cases include description of necropsy; permission was apparently easily granted so that Beni— vieni could search the cause of death, not so that he could learn any- thing of normal human anatomy.“ As a result these accounts are hopelessly confusing if used as an index of what diseases were preys; lent in Florence, but as a record of conunon illnesses, they are richly diverse. Fevers, intestinal worms, hernias, fistulas, choiecystitis [gall— stones], and the sequelae of trauma make up the bulk of the small volume, revealing perhaps as much about what Benivieni found inter— esting as about the illnesses common to the upper classes he served. Of all these only two stand out as possible examples of tuberculous infection. In the first. the daughter of Rogerio Corbineili had almost continual pain in her right flank. . . . At last she died. It was decided to open the body. The femur was found to be eaten away and most of it reduced to powder. Moreover around the os matricis were four yellowish lumps, like balls, three filled with watery fluid, and the fourth raisEd a little above the others, and tuberculated [den— Health Status of Florentines 35 talus], rough, and hard as to the surface, seeing that it was gendered of flesh and black bile.“ This is typical of Benivieni, providing little clinical or postmortem detail apart from attention directed to the site of a patient's principal complaint. His concern was to defend the differing ”opinions and pronouncements of physicians" showing how internal changes could not be easily diagnosed from outward signs. This case might be attributed to a tumor in the bone, but tuberculosis of the head of the femur was before soon the commoner cause of this pathological process.“ To this girl’s case he added an ineresting codicil: "For I also knew the son of Antonio laccetio who suffered terrible pain in the hip and fell first into a state of extreme weakness and then did, as neither physicians nor remedies availed. When his body was cut open a noxious humor [pestifer humor] was found in the hip. By this most of the bone had been eroded and looked as though reduced to ashes."W With two such cases it is less likely that a bony tumor caused both illnesses than that tuberculosis did so. Nowhere in Benivieni's casebook is there a straightforward case of pulmonary tuberculosis with bloody sputum [hemoptysis}, although he describes pleurisy as "coughing and fever and blood coughed up with the phlegm,”“‘" but then Henivieni does not seem to be interested in recording what was typical in Florence, even in his own practioe, despite his considerable clinical experience in hospitals and private practice.“ The only other case perhaps suggestive of tuberculosis is the patient with an abscess over the thoracic spine, which had eroded the underlying tissues so that the heart was exposed to view.” These three examples of possible tuberculosis infection are rare complica— tions of the disease, more to be expected if the organism were preva- lent in the general population.“ To put the medical problems of the Medici in the perspective of the population and times in which they lived, we must look to some other data besides those afforded by imperfect, individual case studies. These other sources are especially important in any effort to assess the levels of prevalence of tubfl'culosis in Renaissance Florence. Even though I believe the prevalence of tuberculosis was high at this period, the lesser, more general assertion I make that chronic illness was as ‘95 Arm G. Carmichael important as acute epidemics in determining patterns of morbidity and mortality clearly finds support from a study of population—level medical data discussed below. Mortality registers are one of the most accessible sources of his— torical data reflecting the overall health status of a population because they encompass a broader segment of the general population than do other records of illness and death. Ignoring, for most of this prelim- inary study, that the circumstances or immediate causes of one's death do not necessarily have any direct relationship to illness and suffering experience in one’s life, we need to know, as a first approximation of the health status of Florentines, w...
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