Renaissance Society of America

Contagion Theory and Contagion Practice in Fifteenth-Century Milan Author(s): Ann G. Carmichael Source: Renaissance Quarterly, Vol. 44, No. 2 (Summer, 1991), pp. 213-256 Published by: The University of Chicago Press on behalf of the Renaissance Society of America Stable URL: http://www.jstor.org/stable/2862709 Accessed: 04/11/2009 04:53
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Contagion Theory and ContagionPractice in Fifteenth-Century Milan*

by ANN G. CARMICHAEL plague, "contagion" is not a very helpful term. Plague is ecologically a complex disease transmitted from rodents to humans via fleas, and human-to-human passage of the disease is uncommon. Moreover, humans do not form lasting immunity to plague and cannot maintain the microorganism in human populations in the absence of infected rodents and their fleas. There can be no "Typhoid Mary" figure in the passage of plague. Nevertheless, popular histories of late medieval and Renaissance Europe, as well as specialized histories of medicine and of public health, champion the emergence of contagion theories and practices based on the acceptance of contagion ideas, as the progressive edge of European defenses against recurrent plague. While contagion theories do not adequately account for the actual biological occurrences of plague in humans, the evidence that surrounded the earliest production and elaboration of such ideas can tell us much about the social context in which they first appeared. What observers found important and what explanatory models they accepted at all stages of the diagnostic process is as revealing of early modern experience during epidemics as is discussion of what actually happened to cause illness and/ or death from the modern medical point of view. In "seeing through" (the literal meaning of"diagnosis") an ill person's observable "signs" and reportable symptoms, medical and lay witnesses to sickness and death attach meanings reflected, in part, in the naming of a disease, a "cause," or a particularly disturbing event or sequence of events.
*All manuscript materials are drawn from Milan, Archivio di Stato, and I am most grateful to the staff archivists who helped me in locating these materials. This paper was originally presented at a conference on the History of Disease sponsored by the Francis Wood Institute at the College of Physicians of Philadelphia, March, 1988. I am grateful for the comments and suggestions of Ellen Dwyer, Arthur Field, Helen Nader, James C. Riley, Charles Rosenberg, Steven Stowe, and especially Katherine Park for guiding my revisions of the original paper. This research was supported by the National Endowment for the Humanities, #RH2o835-87. 'On the standards of diagnosis see Ballester; Lockwood; and Siraisi.

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HENUSED TO UNDERSTANDAND COMBATthe spread of bubonic

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In this way, social historians of medicine would argue, a disease is "socially constructed." The diagnosis of plague, for example, involved a process of distinguishing some illnesses and deaths as cases of plague while differentiating these from non-plague cases. Some part of the set of relevant criteria were obviously medical, some epidemiological, leading a diagnostician to say that a case was one of plague because some important criterion was fulfilled and could be verified by anyone observing the evidence. Of course, to agree on the name or diagnosis observers had to share the same assumptions about what could be concluded from that evidence. A larger meaning for "social construction of disease" might make far greater claims than I shall here as to how the assumptions (e.g., theories) were agreed upon and what kinds of evidence were allowed or discounted. In this more limited study, I shall examine the relations drawn between evidence and assumptions in the diagnostic process and describe how differently-oriented persons in authority wrestled with different experiential data that they gathered by managing, day-today, the spread of plague in a city. Many struggled to link that experience to the concepts invoked by their use of the supradiagnostic category, "contagion," which had different meanings for different diagnosticians. I describe the course of a relatively minor plague, that of 1468, in a relatively large urban center, Renaissance Milan. Most of the elaborate discussions about plague contagion and public health controls based on that assumption postdate the mid-fifteenth century, so I am also describing a relatively early point in the political and intellectual debates about contagion-based plague control. Because the Milanese were wrestling with the formulations of contagion theories and concepts generations before others did, I shall necessarily have to preface description of the 1468 plague with a review of Milanese practices and attitudes to plague before this time. Once this groundwork is laid, I shall provide a detailed description of the ideas and assumptions of medical witnesses, public health authorities, and the ruling elite during this particular plague. Death by itself had become a meaningful social event to Renaissance Italians, who first began to keep records of mortality during the late fourteenth century.2 For the Milanese, the assignation of
'See Carmichael, 1986; and Cipolla, 1972.

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medical cause to death registrations was obligatory after the midfifteenth century. All individuals over the age of two at death, in all years, whether or not plague occurred, had to be assigned a cause for death, as the records surviving after 1452 amply testify. These rich data that Milanese records provide suggest that it is pointless to debate whether medical men or public health authorities first accepted the notion of contagion. The story to follow illustrates that there were two divergent traditions of evidence, argument, and action governing the behaviors of these two different authority groups. How a physician could believe that the disease of an individual patient was contagious depended upon acceptance of a very different view of plague experience from that guiding health officers. Reflecting parts of the society's overall commitment to contagion principles during plague, the Milanese evidence suggests that the variant experiential data supporting these separate traditions in contagion theory and practice permitted general governing authorities, in this case the duke of Milan, to vacillate between the physicians' and the health officials' differing solutions to the management of plague. Public Health Practices in Milan, 1350-1468

Very little is known about the Black Death and the second plague epidemic in Milan other than the fact that Milan, as an inland city, may have escaped infection until 1360. In 1374, however, the third wave of plague to hit urban Italians, Duke Bernabo Visconti promulgated a version of the earliest quarantine laws ever made, concentrating on the restriction of movement from plague-stricken territories into the ducato,the lands controlled by the duke of Milan. 3 In I399-1400, his successor, Giangaleazzo Visconti, an exceptionally able military leader and administrator, took such an active personal interest in plague control that records of procedures at the parish level can still be gleaned from his dispatches and general correspondence. Probably not all of the epidemic controls and strategies for crisis management were novel to Giangaleazzo's administration, but the core program evident sixty years later had
3For the legislation see the Chronicon Regiense, 82; Corradi, 40-42.
1:224-25;

and Grmek,

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certainly been established by this early date.4 The duke intervened in three specific ways. First, he demanded notification concerning all illnesses and deaths in the city, in the process setting up a mechanism for regulating part of the practice of medicine in the city.5 All illnesses were to be reported to the appropriate parish elder (anziano), either by the physician caring for the patient or by the head of household. The parish elder then notified either the officialidelle bolletteor the duke's hand-picked commissar. The specific notification procedures and the regularization of this process were firmly established by 1438 and were repeated practically verbatim during
the tumultuous years of the Ambrosian Republic (1447-1450), the

oligarchy formed after the death of Filippo Maria Visconti left no legitimate heir. Political revolutions did not change this reporting process, which had been extended to normal as well as to epidemic years during this half-century. Second, Giangaleazzo intervened in the creation of an official position, the commissario,overseeing all health regulations in the duchy as well as in the city of Milan. Scattered evidence from smaller Lombard cities during the first half of the fifteenth century suggests that the scheme of confirming the causes of both illnesses and deaths was extended throughout Milanese territory and that in crisis years a second tier of administrators personally responsible to the duke sifted through all the information in order to coordinate defenses throughout the territory. Thus the commissioner's office probably originated as a temporary solution to epidemics. Commissioners were appointed in 1419 and 1424, and again during the

brief-lived Ambrosian Republic. Third, Giangaleazzo interfered in the use of hospitals and hospital resources, regulating how the commune would conscript emergency personnel, possessions, housing, and sustenance for those touched by plague. Ecclesiastics could be fined for burying anyone whose family was not provided a burial license, the end product of the reporting and registration process developed in detail. Religious houses were conscripted for the housing of"poor" who might otherwise die of famine because access to resources was
4On Giangaleazzo's plague controls see Bottero, 1942, 17-28; Pasi Testa, 376-86; and esp. the thorough summary by Albini, 84-101. In general, see Cipolla, 1976, 1417, for comparison of Milanese legislation with that of other north Italian states. sOther aspects of the regulation of medical practice are treated in Bottero, 1943; and Belloni.

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severely limited during the crisis. Other houses or hospital properties controlled by the Church could be assigned care of those recovering from plague (not everyone who got plague died), or even the overflow patient population normally absorbed by the existing hospitals. Thus, at least from the time of Giangaleazzo Visconti, care for the poor and care for the plague-stricken were overlapping concerns of the state, a state that asserted its right to set aside the claims of private individuals and religious institutions wherever the need to combat plague demanded.6 These premises of public health control still operated a halfcentury later, but little real change had occurred. Giuliana Albini's thorough study of the topic teases out the details of plague and general sanitary legislation and practices, finding the only significant change administrators' gradual acceptance of in-house confinement during plague times. Giangaleazzo's approach to plague control involved strict segregation of healthy from infected, placing a heavy burden on officials to remove from the city all individuals diagnosed with plague, and to create houses of recovery that would impede the re-introduction of plague. Firmly believing plague was spread by contact, Giangaleazzo was aware that both those living in the house with the ill person and those who had come into contact with the household were tainted and should be separated from the general community. Early in the century, administrators desperately tried to keep up with the construction of temporary shacks or cabins away from the city or the assignation of monastic or hospital properties for quartering these people, in addition to efforts in providing for those who might perish without state charity. Albini concludes that by mid-century the necessity of quarantining contacts in their own houses became both a political and an economic necessity, even though health officials, applying strict contagionist models, could argue that the procedure would exacerbate plague in the city. Plague would surely spread to all members of the household, multiplying the sources for new cases if quarantine was not both lengthy and rigidly enforced.
6Albini, 63-78, esp. 68. I argued that plague and poverty were firmly associated

during the early fifteenth century, but for an altogetherdifferentreason:mortality experienceduring plagues fueled this administrativeconclusion; see Carmichael, I986. Albini'sbook, unavailableto me when I wrote my study of Florentinedeaths, contains a rich discussionof the late medieval notions of poverty as well as how administrators linked their perceptions to specific plague controls.

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Plague entered Milan in 1449, despite the Ambrosian Republic's best efforts to follow every detail of traditional sanitary procedure, gaining the full cooperation of Milan's College of Medicine as well as benefiting from the contemporary reform of hospitals so that the full resources of these wealthy institutions could be directed to controlling the problems of poverty and famine. Ironically, the very villa Giangaleazzo had used as a refuge from plague in 1400 was appropriated first as a shelter for the mendicant, desperate poor collected from the streets of Milan, and then for the city's first makeshift lazzaretto (pest house).7 In 1450, Francesco Sforza, a brilliant mercenary soldier equally successful later as an administrator, took possession of Milan from the Ambrosian Republic. His victory was aided in part by marriage to Filippo Maria's daughter, Bianca Maria, and in part by the coexistence of this devastating plague in the city, eclipsing the resources of the republic. Sforza made political capital of the population's weariness with war, plague, and famine, but he did very little to change reporting and isolation practices in the middle of the epidemic. He did receive notification personally, probably daily, of the deaths and new suspicious illnesses in the city, though few of these bulletins now survive. By 1452, as plague was receding, the bulletins that had so long been required of parish elders, physicians, surgeons, barbers, and herbalists, reporting deaths in the city by date, age, sex, cause, parish, and certifier of cause-of-death, were written into the first surviving Necrologior death registers.
The basic outlines were the same as in
1400,

but it is worth sum-

marizing the status of public health surveillance with the advent of Sforza rule in Milan. First was death reporting, where by decree, heads of household were to report in writing both illnesses and deaths to their parish's elder. If an individual was under the care of a physician belonging to the prestigious College of Medicine (all were university-trained physicians and surgeons), the physician could by-pass this step on behalf of the family. Barbers had to gain the permission of a collegiate physician before attending any patient; all surgeons, herbalists, and barbers had to call in a collegiate physician if a patient remained in their care more than three days. There were predictable exceptions to these rules: infants and very
7Albini provides full texts of the relevant legislation during the 1447-50 period. For details of the use of Cusago first as poor house, then pest house, see Decio.

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young children or, in some cases, accidental or traumatic deaths, whether by the judgment of the general public (iudiciopublico) or by an elder's testimony. The elders were obliged to submit a daily report of these illnesses and deaths to the officials "deputized for the conservation of health" or the "health commissioners of the city of Milan." The older officialidelle bollette,had by mid-century split its duties, one (the older, original function) governing the registration of all visitors to the city, lodged in private houses or in inns; and one governing the other aspects of health surveillance dating from the time of Giangaleazzo. In other cities of the duchy and in some neighboring territories, the sanitary office was still handled by local officiali delle bollette, but by mid-century, Milan's officers were called "officali deputati a la conservatione de la sanita" or "officiales super sanitate servanda in urbe Mediolani" or simply "commissarii
sanitatis."X

Because Milan had a population of around 60,000 by the I450s, it was large enough that the position of commissar served both local functions and, to some extent, general health controls throughout the duchy. Here the overlapping jurisdictions created some slight management problems, such that the duke could receive details about plague in Milan, or plague in Pavia, Piacenza, Crema, or Cremona, for example, either from the deputies of public health, or from a more general governing agency, such as the Secret Counsel to the duke (Consigliosecreto).Since it was unclear throughout the second half of the fifteenth century where crucial information about plague should first be directed, correspondence to the duke could come from the Secret Counsel, usually concerned with affairs of state such as peace treaties and war; from the duke's personal servants such as his secretary, general informants, and messengers; from the health deputies; from the commissioner; from other cities' boards of health or officiali delle bollette; or from his personal physicians. For example, there were at least three possible copies of any death report in normal years: one from the parish, one permanent record in the Necrologi, and one in a daily summary letter to the duke. During the year I shall discuss below, death reports were carried to the duke from the deputies, the health commissioner, the Secret Counsel, but the permanent death register has not survived. Thus on some days, three bulletins reached the duke, giving the ap'Albini, 9off., gives information for Milan and the duchy.

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pearanceof one agency or individual checking up on another. It was rare, however, that the duke would have been informed about city events directly by a physician. For the most part, the physicians seem to be peripheral to the main process of public health control, that is, they were not the decision-makers. The extent to which input from particularphysicians may have been crucial to changes in public health practices is important, and a question to which I shall return shortly. Some changes in public health practices accompanied Sforza rule in Milan, however much they built on older traditions. Francesco Sforza's relationship to the process of plague and general health surveillance, insisting that he be fully informed of the minutiae of health in the city at all times, recalled something of the personal control exercised by GiangaleazzoVisconti. FrancescoSforza otherwise appears to have been concerned most with the reform of hospitals and the aggregation of their extensive properties in the creation of a central receiving and acute care hospital, the famous Ca'Grande or Ospedale Maggiore. Sforza dedicated the grounds and inaugurated the building of the hospital in 1456.9 He seems to have left other details of health control to his secretary, Cicco Simonetta, and to his personal physicians, especially Benedetto da Norcia. Francesco Sforza died in 1466, leaving the government of Milan in the hands of his wife, Bianca Maria Visconti, and Galeazzo Maria Sforza, his oldest son. Mother and son shared controls for just a couple of years, her voice usually the stronger, until three simultaneous processes effectively placed young Galeazzo Maria in full, uncompromising control. First, he completed negotiations for a politically superb marriage to Bona of Savoy, bringing Genoa into Milanese control. Though only in her early forties, Bianca Maria failed to keep ahead of chronic illness. And finally, plague reached Milan. In 1467, plague, common to all the cities and territories of southern Italy, crossed the river boundaries patrolled by the duke's men. In 1468, it reappeared in the city. Because Galeazzo Maria planned his wedding celebrations to include a triumphant tour of his domain, beginning in Genoa and ending in Milan, his personal involvement in plague surveillance and control was much keener

9Spinelli.

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than his father's ever had been. o All levels of Milanese administration ultimately had to contend with his understanding of the causes of plague, his preferences for exercising controls, and ultimately, his anger at their failures. But there was enough of a political vacuum created after the death ofFrancesco Sforza that the young duke had to craft his own understanding of the role physicians and health officers should play. Galeazzo Maria Sforza's correspondence with officials betrays his attempt to "micromanage" the epidemic from a safe distance, inserting his orders and ideas into the process of plague control almost as much as did his great-great-grandfather, Giangaleazzo Visconti. Both officials and advisors were quick to inform the duke what his opinions about plague control should be. Galeazzo Maria's own anxieties about the wedding plans as well as his political need to assume unchallenged control of Milan and the duchy may account for his unprecedented involvement in the medical and public health details of an unfolding epidemic. Medical Traditions in Milan, 1350-1468

Milanese physicians had an ambivalent relationship to the use of "contagion" in medical theory, even though the College of Physicians had since 1396 made plague-related exceptions to its rule that collegians should attend the funerals of others in the college. If a colleague died with a "contagious or pestilential malady," his fellows did not have to go to the interment or carry the bier. I Given this unwillingness to touch plague, the physicians as a group may have been reluctant to perform any kind of postmortem verification that a person died of plague. College physicians did perform autopsies, presumably in the study of human anatomy, for the statutes of both the college and the city of Milan in 1396 allude to the yearly provision of a corpse and a place for dissection. 12The physicians did not, however, express unqualified support for a contagion model of plague, nor did they make recommendations similar to those public health officials urged. The reasons for their reluctance are
'Corradi, 5, 244-46. "Bottero, 1943, 104. '2See ibid., 105; and Belloni, 671-72. One year a male corpse would be provided by the podestaof Milan, the next a female corpse. The large hospital Brolo was the typical location for dissection. One of the anatomists, Iacopo da Firenze, served as the surgeon to the Sanita in the 1450s plague. Toward the end of the century autopsies were performed with such regularity at the Ospedale Maggiore that they had to be regulated by the directors. See Spinelli, 112.

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lodged in the ways in which a diagnosis was made when a physician trained in Galenic medical theory was confronted with an ambiguous clinical history or ambivalent "signs" on the body of the ill person. The following, tortured description of what seems to me a straightforward case of plague will help to illustrate the clinical problem with contagion theory in the fifteenth century. Here the principal physician to the Sanita, Giovanni Catelano, reported a suspicious case on 20 May 1468: de' Magi,thirty-five Gotardo aboutthe hour yearsold, fellill on Tuesday of mass,withanaposteme in hisleftgroin,aboutwhichcaseI amdoubtful Thereis thatwhichaccuses andthatwhichexcuses.First andperplexed. theshorttimeperiodaccuses. Buthis horseback he ridingexcusesbecause was unaccustomed to it andbecause an aposteme canarisethis way. He hasa son who Mondaywas bittenby a rabiddog, . . . whichcausedthe father to seizeandto weaken eitherin compassion fortheson considerably, or possiblyby contagion of rabies[contagione for is among rabies rabiey], thecontagious home[after [diseases]. Tuesday eveninghe returned killing thedog]withthisweakness, andburning nausea whichhave andaposteme
persisteduntil now (i.e., for three days). But I could be persuadedthat the

venommorethanby pestilential aposteme mightbe caused by the rabies fever.Forrabies is of a coldanddry,melancholic humor,andits respective venommoredetrimental to the spleenthanto the heart.[Herefollows a of what kind of material Catelanoand other doctorsthink description but he has become mightbe insidethis swelling.]The urineis laudable, alienated overthepastnight,andhasbeenvomitingbitterac[stuporous] to alleviate I shallvisit him andthink ids. Sincethis appears his suffering over the case.'3 Aside from the fact that the physician has chosen to take the patient's story seriously, this account shows how Catelano was simultaneously wrestling with the different causative physiological processes that could explain an acute bubonic swelling and with the nosological dimensions of contagious and noncontagious diseases. In other words, Catelano's interest in whether or not rabies belonged among diseases classified as "contagious" may have been linked to here-unrehearsed debates about whether plague should also be categorized as contagious. But deciding what caused Gotardo's aposteme involved a different sort of evaluation, one reviewing all the possible ways in which apostemes could appear. In this initial case report, Catelano suggests that Gotardo could have
'3Milan, Archivio di Stato, Miscellalea storica brfizesca(hereafter, MS), 2, 1no. 41.

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acquired the swelling traumatically, while at the same time his body was weakened with the absorption of rabies poison. Resorption of the aposteme and absorption of the poison together produced Gotardo's fever, nausea, vomiting, naturally so because a vital organ, the spleen, was compromised. From our point of view, of course, this particular rabies story cannot possibly account for either the bubo or the malaise. While it is possible that the heart of this diagnostic dilemma lay with the credence the physician placed in the patient's story, it is necessary first to examine the medical issues Catelano presented. The reason humans died from any acute disease had to be explained by means of sudden humoral imbalances, largely thought of as a putrefactive process. Plague was normally viewed as a virulent putrefaction of the humors, killing rapidly as the heart was suffocated. 4 The body's attempt to deal with the disturbance resulted in the bubo or the skin reaction, literally throwing out poisonous putrefactive by-products from the body. It is the word these records use to describe signs seen: butato,"thrown out." In the sixteenth century, physicians would turn to examine the putrefactive process independently of the specific disease needing explanation and would begin to ask what caused the putrefaction of the ambient air that in turn caused deaths from plague. s In other words, they would focus on the ultimate, inciting causes. But in the fifteenth century, the physician could look at a bubo and see either "accidents" of a physiological process of infection, literally things that derive from the first insult to the body, the external manifestations of a hidden disruption of normal body functioning; or he could see these external manifestations as diseases in themselves, possibly following other clinical courses than that seen with plague. In Gotardo's case, Catelano thought it possible that the aposteme was generated exteriorly, initiating a local putrefaction, and then spread medially as the rabies poison debilitated its victim. Melissa P. Chase's superb study of Montpellier physicians active between 1348 and 1450 clearly distinguishes the physicians' concern with whether they were seeing contagious apostemata or witnessing pestilential fever manifested by the "accidents" of these

'4See Singer; Castiglioni; Sudhoff; and Chase. 'SSee Palmer, 1978; Nutton; and Palmer, 198I.

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6 apostemes. What made the former contagious was the poison they contained, an important point to which I shall shortly return. On the possibility ofnoncontagious apostemes, much the same distinctions are made by Milanese diagnosticians as in Montpellier, so it is not surprising to find detailed differentiation from plague of apostemata or swellings that were believed to have originated otherwise. Three examples from 1468:
[une 6, a thirty-year-old man], reseen after death: found to have an aposteme behind the left ear, but already mature, emitting pus mixed with blood, which is believed to have come by way of a crisis of the illness which finally took him after twenty-two days; not worrisome, according to Catelano.
Bertola de' Rigoni, twenty-two years, . . was seen while alive and

found to have swelling or aposteme in his left side, toward the front, that was said to have been caused by a severe blow by a piece of wood, which [explanation] I trust to a degree. I was shown the place, which had a certain lividness and a little excoriation, and the urine was good and abundant, but unexpectedly he died after twelve hours. I returned to see the body. Another large swelling over the groin was found in addition to the other. He died Saturday, that is, yesterday [une 6] at twenty-two hours. By thejudgment of Catelano. [August 5] Emanuel, servant of lord Ubleto da Fisco, twenty-fiveyears-old [died] from a bubo [dragonzello] in the right groin, because of an ulceration of the propoltius[?] due to an ill-considered application of constrictive medicines. The putrid matter turned back inward to the interior and this caused a continuous, proportional tertian fever, not suspicious in thejudgment of Maestro Stefano da Trivulio and Dionysio de' Ceruti, surgeon. '7

Earlier reference to rabies is rather more difficult for us to understand because we live a post-Pasteurian world that recognizes rabies virus has an incubation period of at least two to eight weeks.
i6But Chase has us understand"accidents"by the term "symptoms," which has had a long and variedmedical history and may mislead many readers.Symptoms currentlyareconsideredto be the subjectiveexpressionof illnessby the patient,specifically what causessufferingto an individual.See Foucault,90-94 on the earlymodern medical usage of "symptom"; and King, 73-89, for what "symptom" means today. '7MS, i, passim, by date. The last example, however, is found in Sforzesco, Carteg883, 5 August 1468: "Emanuelfamulus domini Ubleti de Fliso, annorum gio interno, xxv, [decessit]a dragonzelloin inguine dextro propterulcerationepropoltii ex indebita applicationemedicinarumconstrictivarum.Reversaest materiaputredaad intra. Et sic causa est febris tertianacontinua proportionalis,sine suspectu, iudicio M.ri Stephani de Trivulio et Dionysii de Cerutis, cirugici." It is quite possible that this man had a plague bubo lanced, treated with poultices and constricting unguents. Surviving the first disease, he succumbed to secondary infection of the lesion.

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But according to medieval tradition, rabies was classified among a short list of "contagious" diseases, diseases that could be acquired only through contact with someone (possibly an animal). The list of contagions was short: phthisis, ophthalmia, anthrax, epilepsy, "sacred fire" (either ergotism or erysipelas, or both), scabies, rabies, and leprosy. 8 What made a disease categorizable as contagious related more to notions of the disease's transmission than to the specificity of the individual disease phenomena. For example, measles and smallpox, indeed most of the "exanthems" or rashbearing diseases, reflected signs of inward processes registered on the body surface. The modern concepts of disease specificity, for example, that the measles rash is identical in each and every person who suffers it, was first most clearly stated by Thomas Sydenham in the I68os. As early as the I 540s, Girolamo Fracastoro settled on the idea of a "precisely similar corruption," which approximates the idea of specificity. '9 Before this time, Galenic emphasis on the determinative influence of an individual's unique humoral composition governed most clinical thinking. Instead, medieval and Renaissance contagious diseases fit better into explanations of poisoning. It is in the treatises on poisons, in fact, that rabies is usually discussed, and poisons were a medical topic of longstanding interest to the Visconti lords of Milan.20 Thus it is interesting that one subgroup of physicians, not under the control of the College of Medicine, did have a strong tradition with regard to the idea of contagion in plague. These were the ducal physicians, who from the time of Bernabo Visconti presented plague treatises that are frequently seen as the earliest sustained commitment to a contagion principle. Cardone de' Spanzoti was the first of these, presenting his De preservatione a pestilenciato the Visconti in 1360, in which he advises the usual flight from turbid, humid airs, rectification of the

'8Grnek, 25ff., provides a different list of the traditional contagions than does Nutton, esp. 15-I6 for the rabies example, with the Galenic texts cited. Fracastoro, 125-34, devoted a chapter to rabies as a contagious disease, following suggestions he found in Aristotle, Galen, and popular tradition. Guainero wrote that rabies can manifest this quickly after infection; see Thorndike, 4: 226. Temkin provides yet another list of the diseases commllonly assumed to be contagious during this period. I'Winslow. 2Thorndike, 3: 525-45. Thorndike, 4: 217, explicitly links the literature of contagions and the literature of poisons.

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air by burning woods and herbs if flight is not possible, all because
the "morbo pestilenziale e contagioso."21

The most famous of all fourteenth-century plague tractates, surely one of the two most often reprinted later, was Pietro Curialti da Tossignano's Consiliumpropesteevitanda,dedicated to Giangaleazzo Visconti in I398. Tossignano has the most definite notions about contagion theory of any physician before the sixteenth century.22 He argues that "it is safer to move to a region where there has never been an epidemic than where pestilence has reigned even six months back, since the 'reliquiae' will remain and, acting like a ferment, will infect those who come into the locality." And he speaks both of contagious houses and the poisonous content of apostemes. Tossignano is justly famous because he was willing to address both the public health dimensions of plague controls and the clinical treatment of individual plague cases. This was not true of collegiate physicians. For example, Antonio Guainero became one of the most prominent of Milanese physicians during the early fifteenth century, dedicating his treatise on plague and poisons to Filippo Maria Visconti. Guainero taught at
Pavia for a major portion of his long career in Milan (I412-ca.

1448), and counted two of the Visconti court physicians among his preceptors.23 Delivering his treatise in both longer and abridged forms sometime before 1440, Guainero was possibly trying to secure Visconti patronage. Guainero was predominantly a clinician and clinical teacher, and his plague treatise, while claiming to be drawn from standard, long-known medieval sources, is at times quite different from comparable literature of the day. He prefaces the work by acknowledging that "some say plague is a contagious disease" transmitted in touching, even though much of the discussion, following tradition, maintains that plague is generated first by corruption of the air.24 Guainero, however, does not venture a dis'Panebianco. See also Belloni, 61 3. Two other physicians to this generation of Visconti wrote plague treatises: Giovanni Dondi and Maino de Maineri. The latter was probably the son of Visconti physician, Pietro Maineri. See Castiglioni; and Palmer and Zitelli. -2See Singer, 187-89; and Mazzini. :3Thorndike, 4: 2 5-3 I, 674-77. Luchino Bellocchio and Giovanni Francesco Balbi were personal physicians of Filippo Maria Visconti, as were Petrus de Monte Arano and Stephanus de Burgo, to whom Guainero refers on other occasions. See also Lemay. -4Guainero, f. i68v: "Dicitur et aliter pestis contagium a contangendo quia quem tetigerit popuit vel quod ex unius contactu ad alios se facilinie transfert. Et ideo Isidorus tertio ethimnologiarurn pestilentia inquit est contagiumn quoddumn unumncomnprehendit

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cussion of public health measures for the control of plague, deferring the matter to appropriate communal authorities.25An unwillingness to dictate public policy seems to differentiate the scholastic, university-trained collegiate physicians from ducal physicians not allowed such a refuge. Strikingly different are the policy recommendations made by physicians who advised the Visconti and Sforza dukes about plague. The last of these, in the period before 1468, was Benedetto Reguardati da Norcia, who became the personal physician to Francesco Sforza when the latter was still a military condottiere. With Sforza's rise to power, Reguardati was called upon to advise the duke about plague controls, which Sforza passed along to the Secret Counsel. 26 In 145 I, Benedetto was concerned with assessing the health conditions of the city, specifically the ambient air, but he also proposed an interesting solution to the trade problems plague controls presented. He suggested the equivalent of a neutral zone, or portion of road between Milan and Pavia, where goods might be safely exchanged: a solution to quarantine problems with commercial goods that would become common a century later.27 A member of the Secret Counsel in 1464, Benedetto may have had further direct experience with managing plague. But most important to the events of 1468, letters from Reguardati to Duke Galeazzo Maria Sforza in 1467 reveal his significant intermediary role. On 8 May, 1467, he reassured the duke that all the identified cases of plague had been imported, that is, they resulted from contact with plague outside Milan. He urged the duke to protect himself by avoiding all contact and conversation with anyone who came from places where plague reigned and to interpose human barriers when he had to deal with anyone who could have had contact with
plague.
28

Ten days later, in a letter concerned with many diplomatic

ad alios celerime transit." Interestingly, Guainero is aware of Isidore's discussion of contends that Recontagion in the Etymologies (7th century A.D.); Nutton, 20-21, naissance authors overlooked Isidore. 2'Guainero, f. 70ov:"Et illo modo per viam contagii plures civitates ac ville fuerunt infecte. Qua de re reipublice gubernatores conversationem locabitantium infecta suis debent inhibere immo solum eius sive de propinquo locutionem." 26The letter, with others is printed in Deffenu, 140.
27Ibid., 21-22. 28Ibid., 159-60, prints the letter. Benedetto does not use the word "quarantine," but the advice does seem similar to his solution to the Milan-Pavia commerce of 145 1:

"ve dignate havere reguardo alla vostra persona et a quelli che ve stanno dappresso che ne voi ne loro non habbiano praticha ne conversatione con persone che vengano da loci suspetti, et spaciare le facende per mezo de interposite persone."

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and business matters, Benedetto remarked that he knew Milan had been relatively plague-free, until he got "the list of the officials of the Sanita at 22 hours today." It is interesting, of course, to speculate that individuals among the physicians to the dukes, or even just this one, intercepted the lists of the deaths and illnesses of the city, filtering the information that went on to the duke. Benedetto also mentions his devotion to the contagion model: "[these cases] do not surprise us or cause anxiety, because we clearly see them to occur through contagion." Thus the city could be purified easily.29 Reguardati wrote very traditional health advice and conferred with colleagues at Pavia on medical matters. He subscribed to the astrological medicine especially favored at the university at Pavia, all of which suggests that his connections with the health magistrates stimulated his open subscription to, even innovation regarding, contagion practices (not theory).30 Until young Galeazzo Maria came to power at age twenty-four, the dukes of Milan may have been comfortable with physician intermediaries. Galeazzo Maria was delivered and raised by Maestro Benedetto, who described himself as "more nurse than physician" to the heir, and the duke was clearly torn by Benedetto's supplications to return to Tuscany, a long-cherished desire, and his own mother's demand that the dearly beloved physician remain in her service.31 Only upon Bianca Maria's death in October, 1468, could Benedetto leave, severing one sure link between university physicians, the duke, and health magistrates. Negotiating the Diagnosis of Plague

However sophisticated the observations of plague infection and death from plague revealed in many of the physicians' records, the absence of a theoretical defense of the transmission of disease by
'9Sforzesco, CartceViointerno, 880, 18 May 1467: "Per lo dio gratia doi di passati in Milano non e suto ne morto ne Infecto alcuno de peste. mal al presente ad hore vintidoy me venuta la lista del officiale della sanita che nel borgo de porta Comasina che in uno stallo di piu fameghe ne sonno infirmate de pestilentia dove nelli di passati n'erano morti tre. Questo non ce da maraveglia ne grande affanno perche vedemo manifestamiente essere per contagione. La quale per la gratia de dio se spera che legiermente se debba purificare." 3On1Benedetto see also Cotton. 3'Letters of these negotiations among the duke, Benedetto, and the duchess appear in Sforzesco, Cartcggio intcnro, 883, 15 February 146x (with a second letter this day from the duchess to Cicco Simonetta to urge the duke further), and in other letters reprinted in Deffenu.

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contagion hindered direct discussion of the problem of contagion with public health officials. While those trying to anticipate the spread of an epidemic understood the problem of contagion theory as one linked to Hippocratic notions about how an infection could be transmitted from one person to another, physicians focused on the problem at the level of distinguishing which humans were in fact infected with the plague poison or putrefaction. Thus physicians regarded the means of conveying the disease from one person to another largely irrelevant to pressing diagnostic and therapeutic issues. Contagion was not the starting point for medical thinking unless one began by accepting that diseases, like poisons, were individual entities entering human bodies. Thus lvhat was transmitted was ultimately to become more important to physicians' theoretical understanding of contagion than how disease could be transmitted, for Galenic and Hippocratic theory seemed to account adequately for both successes and failures to transmit disease from infected to healthy individuals. Frequently, plague had to be the conclusion even though no clinical evidence could affirm the diagnosis, thus challenging and widening the physicians' basis for making a diagnosis. Clinically, physiologically, plague was known by two very different sets of descriptive evidence. Most of all, it was a profound imbalance of the humors that accelerated putrefaction around the most vital of all organs, the heart. In order to apprehend that process externally, physicians had to rely on outward "signs" and discrete changes in the patient's urine. On the other hand, plague was suspected if a person progressed from health to death in less than five days, or if he or she died in a place where other plague deaths had occurred. Here classical theory had no framework for translating epidemiological information into clinical sign or symptom. An epidemic disease, since the time of Hippocrates, was an epidemic because it had a cause common to the entire population affected, such as corruption of the ambient air, or through contaminated food, or through astrological changes impinging upon the terrestrial world. The intersection between clinical information and epidemiological information was as difficult then as it often is for laymen today.32
32Many nonspecialists today trying to understand infectious diseases accept strongly deterministic versions of the germ theory of disease and reject statistical models of causation. In fact, many things we consider to be discrete diseases fail to satisfy Koch's postulates for proving the causal relationship. See Evans.

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"Plague" in practical, emergency conditions could encompass far more than the texts allowed. But even had the narrower, clinical diagnosis carried greater weight, positive plague "signs" included: "black measles," "red (or black or violet) signs," "plague measles" (even the expectation that these would appear), any acute swelling, any "carbone," "pestilential fever" (an acute, high, continuous fever), "malignant pustules," anthrax-any one of which could occur alone or in combination with a bubone, glandula, dragonzello,or other aposteme. In such circumstances, it was difficult to view plague as a discrete disease, unique in its clinical appearance. Because the doctors were diagnosing more with an eye to process, to the pathophysiology of plague rather than the essence of plague as a thing foreign to a body, passable from one to another, their best efforts to comply with the health officials tended to undermine contagionist efforts. "Today we have two cases," the deputies wrote, "through which, according to thejudgments included below, we are doubtful and perplexed." With that, May 2I, they repeated the language of Catelano the day before (the rabies case above): "And for clarification we diligently consulted the physicians deputized to oversee this, who through that which they have been able to understand and know by the script of this judgment, neither absolve these cases entirely nor condemn them."33 One of the cases involved the female servant of a doctor-this time the prestigious collegian Maestro Francesco de' Medici da Seregnio. She was twenty-five-years-old and had an aposteme in the right axilla. The case was arguable because she had several times before had difficulty (malo) in that spot, the part could have remained debilitated and "could have easily generated that aposteme, not, however, pestiferous." The case report does admit that whatever the cause of the swelling, the woman's urine was "confused," possibly meaning cloudy, and she was in pain "from her head all the way to her feet on this same side." On the other hand, surgeon Dionysio equivocated, the fever was not intense. Perhaps Dionysio was swayed by the logic of the great physician, whose home would be sealed if he could not persuade the young surgeon the case was really more complex, but the Sanita also had to believe the story in order to support their subsequent actions.34 In another case, a
33MS, 2, no. 44. 34Francesco de' Medici da Seregnio matriculated in the College of Medicine 31 May 1454; see Bottero, 1943, 1i. Before his college appointment he taught surgery in the

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twenty-three-year-old woman with a "pestiferous carbone," or eschar, would have been a clear case of a plague pustule, but the lesion appeared on the left breast-not typical of plague. Thus the deputies decided to let the physicians wait for surer signs. If the women worsened, it would be plague. If not, not.35 Believing in contagion as the magistrates did, very few deaths occurring in a confirmed, infected house, or at the lazaretto, or in the cabins, were ever considered anything but plague. Singly, new cases awaited the surest medical "signs." Rapid succession of deaths in a household helped to speed diagnosis and action: "Today [23 May 1468] we do not have any new case except a woman named Catharina, the wife of Tomaso da Pergamo, who died recently under suspicion; she became ill yesterday and tonight will be taken to the deputized place."36By the same measure, recoveries begged a diagnosis of non-plague. Arguing, as usual, that they were exercising extreme caution, the deputies wrote the duke May 27 that they exported everyone in Giovanni Bono's house to San Gregorio, despite the fact that the house was large enough that they could have been separated from neighbors effectively. But "we were not even certain that the case was truly suspect, there being at the same time in this house another sick person who recovered."37 Meanwhile, every time there was a reprieve in the death count or the pace of new cases, the deputies were willing to take advantage of the physicians' ambiguity in diagnosis: "Things are going well, through God's grace, and we hope they continue to improve. These physicians are beginning to change their sentence and judgment, and now hold the firm opinion that no excessive news will follow, because now some tertian fevers have begun to appear and these do not convert into suspicious illness, from which we take much hope."38 Fuller discussion of the events of 1468 help to illustrate

short-lived Studium of Milan; see la Cava. Dionysio appears in the Necrologi records in the late 1460s, but is both a foreigner and a surgeon, never joining the College. He died in 1504, at the age of 80; see Motta, 256. 3sMS, 2, no. 44: "Pur per piu secureza havemo deliberato che questa sera sia revista et secundo sara il caso si guovernaremlo. Domani per il nleglioramnento, or per pegioramento che fara la fantescha de dicto M.o Francescho se intendera chiaramente si sara sospecto o nonl." 36Ibid., no. 46. 37Ibid., no. 50. 38Ibid. (27 May).

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how physicians and health magistrates were called to defend their separate traditions of contagion theory and contagion practice. Galeazzo Maria Sforza and the Path of Plague In 1468, physicians, health officials, legislators, the duke, and his personal staff were all involved in the process of identifying and outlining what conditions presented a threat to the state. Effectively the Milanese public authorities delimited the parameters of contagion practices before physicians could explore and articulate the ways in which contagion theory posed serious challenges to Hippocratic/Galenic physiology, for the physicians were most concerned with understanding how contagious disease could undermine body defenses. Then as now, clinical data did not neatly address epidemiological questions, though the debate was not seen in these terms. Most of the numerical data about this epidemic must be gleaned from letters, because no bound registers of the Sanita's Necrologi now survive. 39But the Sforza dukes retained so much of their personal correspondence, among which many notices of death and illness reports during 1468, from both the deputies of health and the Secret Counsel, that we can reconstruct how the process of diagnosing plague was negotiated and argued, the practice behind an emerging theory of contagion. It was probably inevitable that plague would reach Milan, for all the major cities of Italy from Rome northward were stricken between 1464 and 1467.40 The deputies of health repeatedly warned the duke that additional funds would be necessary in posting guards at the gates, rivers, and major thoroughfares flanking the duchy. Early in March 1468, a few plague cases were identified inside Milan, most of them associated with one large household.41 After a few satellite cases appeared in late March, there was a period of calm: "for twelve days now, by the grace of God, no case of plague has followed [the cases in March]," the Secret Counsel wrote to the
3'A fire on New Years' Eve, 1502, destroyed much of the building in which the health officials worked, probably accounting for the numerous lacunae in the late fifteenth-century series of registers. The scribe notes this in the 1503 register, and the text is published by Motta, 244. Zanetti further describes the Necrologi series. 4Corradi, I, 4, and 5, ad ann1iiir)1. 4The earliest surviving notices come from late March but consistently refer to plague cases among one large household, the Lampugnani, e.g., MS, 2, no. 2, 25 March 1468.

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duke on April 6.42 But later the same day the counsel heard rumors that a thirteen-year-old boy died "not without suspicion of plague," and they immediately contacted the deputies for confirmation. The deputies of health in turn dispatched their physician, collegiate physician Giovanni Catelano, who had extensive experience diagnosing plague during the 1450-52 epidemic. Catelano reported that he was in agreement with another college physician, Maestro Marco da Roma, that the signs surrounding this death warranted caution. Although the boy's urine gave no clear evidence of plague, and he died after an eleven-day illness, the inguinal swelling was a new finding when they inspected the corpse. Catelano thought that perhaps the boy had arisen too soon after his febrile illness and this was a recurrence resulting in an aposteme, exacerbated further by rainy weather. Nonetheless, Catelano admitted that the course of illness could be attributed to a body "disposed to contagion."43 Marco's report (via the deputies' letter) noted the swelling in the right groin, a continuous fever for eleven days, and blood-tinged urine that could not rule out the fever as pestiferous. The Secret Counsel decided to impose cautions despite the physicians'judgments, giving the household the option of remaining under house arrest or going to their villa. They were to stay separated and not have any dealings with others.44 Officially this was thus judged a plague death even though the medical evidence was equivocal. The duke's magistrates superficially accepted the medical judgments about early plague cases but separately concluded that plague controls should be applied whether or not these stricken individuals actually died of plague. In taking the doctors' testimony with a grain of administrative salt, the deputies and Secret Counsel were also assuring the duke that their view of the situation was safer for the city than the physicians' more tedious analyses. Ten days went by without another worrisome death, but the officials were clearly unsettled. The next official plague death on I6 April, an eighteen-year-old girl who had been ill for four days, was attributed to her living next to the house of the first cases of early March. The physicians almost certainly agreed that she had plague, because they reported a bubo in the left groin and "succeeding In this case no other potentially confusing deevents" (accidentibus).
42Sforzesco, Carteggio interno, 883, by date. 43MS, 2, no. 3, 6 April 1468. 44MS, I, no. I36.

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tail was offered. We can infer from surviving correspondence that the duke was informed when this girl first fell ill, for Hector Marchese,45the health commissioner himself, wrote to the duke on April 17 that he had gone to visit another member of this household because the duke so ordered him. The ill man that he saw was then exiled from the city, to go to his villa or to one of the designated plague houses, along with three siblings. Hector assured the duke that if this man disobeyed in any way he would be punished "in a manner that would provide an example to others. "46Another death on April 23 called forth plague controls because an immediate neighbor of this six-year-old girl had died a few days before. As in an earlier case, she showed no convincing signs of plague infection, but the girl had an enlarged inguinal gland. Though Catelano found the urine "good," provisions were made. Catelano was not willing to judge this case plague on the basis of a "glandula" alone, because urinalysis was a crucial factor for him, but as the physician appointed to the Sanita he acquiesced to the demand for precautions.47 By late April the Secret Counsel and the deputies of health had translated their worries into a set of provisions, bracing themselves for massive evacuation of the city even as they offered up an explanation to the duke of the origin of the illnesses and deaths identified. One neighborhood around the Cinque Vie (Five Points or Five Streets)48was seen to account for almost every new case of confirmed plague. The original cases in early March had occurred in the parish of St. Pietro della Vigna (see map), and all the satellite cases of March and early April occurred in this or a contiguous parish. The first mention of Five Points occurs, however, in a letter of 27 April from the Secret Counsel, noting a new case in a man named Maestro Legutero. At this point two different shelters in the countryside were set up to receive healthy suspects, and San Gregorio was designated to receive the ill.49 All the guards on passes,
45Mostproper names in the Sforza archives appearin Latin, and I have translated them to Italian. Hector Marcheseis the exception: because he always signs his name "Hector," even when writing in Italian, I have preserved this form. quanto me scrivi la excellentia Vostra circha il fato di Ambrosio, nepote di Symone Mantegatio. .. ," thus alluding to a letter from the duke to Hector.
47MS, I, no. 292. 46MS, , no. . This story is appended to a normal death report and begins, "o visto

48A nineteenth-centuryphotograph of the area is provided by Branduani,72-73. blame for plague away from administrativeerrorto the argumentthat plague was everywherein Italy, especiallyin the principalcities with which Milan traded.See Albini,
101.

49MS, 2, no. 6, 27 April. One of the purposes of this letter seems to be shifting the

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Santa Mariaal Circolo

MAP

OF MILAN

WITH FIFTEENTH-CENTURY

PARISHES

roads, and rivers were put on full alert, much like closing the barn door after the horse has escaped! The surviving letters from the end of April and first week of May reflect only the tip of the iceberg of a growing panic in the city. Conducting business normally became less possible as the circle of contacts of plague cases and plague houses widened. For example, one of the members of the Secret Counsel failed to show up for work. The duke, somehow informed of his absence, immediately demanded that his salary be withheld. On 2 May the deputies wrote to explain that the man's daughter had entered the house of a priest who subsequently died of plague; thus the councilor had voluntarily absented himself from the city for a few days.5s Within a week's time the city would empty of its better citizens, including the duke's mother and her extensive entourage, bound for her dower city of Cremona.5s Galeazzo Maria's wedding was set for midsummer, and wealthy Milanese would normally have housed dignitaries attending the wedding, so the exodus was a matter of utmost concern
SOMS, 2, no. 9. S'For a good discussion of flight from cities during plagues, see Mazzi.

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to all officials. If those who fled were to return, they would somehow have to be persuaded that plague was not a threat to them in the city. If the plague indeed spread by personal contagion, rather than by mere proximity to infected houses, this kind of social pressure could be relieved if plague could be diagnosed early enough to remove the sources of contagion before other individuals were inadvertently exposed. And so the process of diagnosis was to come under scrutiny during the month of May. On the first day of the month came a report of the mortal illness of a twenty-five-year-old female servant of Lord Scaramuzia Visconti, who, together with his large household, was lodged in the Castello Sforza as the duke's guest. Catelano was sent to determine the cause of the servant's illness. Although he viewed the patient's urine and admitted that it was cloudy or "turbulent," a cause for worry, his report does not indicate clearly whether he actually saw Caterina. Instead he could have made his diagnosis through an interview, or case history, taken from members of the household. She had a swelling in the groin area but supposedly was debilitated by fasting ("ex defectu necessarii regiminis pro vita") and may have received treatment, specifically inducing sweating and opening the lesion in order to evacuate the noxious material causing her illness ("putabam eam ex toto evadere per copiosum sudorem et amotionem illius eminentie in coxa. ")52Whatever procedure was done, it didn't resolve the problem, for Caterina was close to death. Perhaps the cloudiness of urine was a further sign of the concentration of putrid matter in the body. Surely the ambiguity in this report reflects some measure of the political delicacy of a plague diagnosis inside a household protected by the duke. All would have to be evacuated or confined to quarters. A second case this same day had placed an entire family under or pustule in the latsanitary interdict because the man had a carbone of his eral part left eyelid. Though this man's urine was judged not suspicious and his death occurred after a seven-day illness, normally outside the range considered indicative of plague, "dubius valde est," Catelano reported. It is possible that the diagnosis of plague in this case had little political consequence, so the disparity between the physicians' diagnosis and the deputies' decisions could be ignored. But a plague physician as experienced as Catelano was
52MS, i, no. 307.

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not governed easily by the politically or socially powerful. Two days later, May 3, the servant Caterina died, the concentration or swelling reappearing in the groin. "I do not know what to judge this other than plague," Catelano reported. Also on May 3 the duke's deputies wrote that a seventeen-yearold boy who lived near the Five Points had manifested a sign ("butato el signo de infection")that could not be securely identified as plague. Here the victim, not yet dead, was only suffering a fever, and his father, a citadinoand notary for the city, might have been known to the duke. "But by the father and by many others it is presumed that this case proceeded from the house of that Maestro de' Laghuti" (probably the same as Legutero noted above for April 23). The deputies' next letter, May 4, noted the boy's death and that of the wife of Guido de la Croce, a builder, claiming that they had already informed the duke about both cases, as plague cases, and that they assumed these two and a girl who just fell ill all to have acquired plague in the Five Points. Finally, 5 May, a sixteen-year-old cleric associated with the church of S. Pietro all'Orto fell ill, with a high fever and vomiting: "This new case is presumed to have proceeded because this cleric conversed with a priest named Antonio, of the church of S. Maria Pedone, who had practiced in the infected house of Petro Crispo near the Five Points."53 All would be taken out of the city, and the deputies grimly noted that cabins would have to supplement S. Gregorio as places for plague victims.54 The first of these three cases had glandular or bubonic swellings in evidence of plague. Thus carefully noting the precise chain of infection for each and every case of plague, the deputies' letters in early May are optimistic that careful case tracing and aggressive separation of the healthy from the potentially infected would protect the duke's city. No more than three people died each day of plague, and all "proceeded from contagion, taken in that neighborhood of the Cinque Vie. In
S3Ibid., no. 225, 5 May 1468: "Questa matina siamlo avisati che Martedi prox. passato al Clerico del preyto de la Clesia de S.to Petro al orto de questa vra. Inclita Cita de etade circa anni xvi asalto el vomito cumnla febre grande: Nuy subito gli havemo mandato el Catelano quale per il suojudicio lo mete suspecto. Questo novo caso se prosume sia proceduto per havere havuto esso clerico conversatione cumnuno preyto Antonio beneficiale de la Clesia de S.ta Maria pedone el quale praticava in la casa de Petro Crespo infect. vicina ale Cinquevie. Havemno ordinato de miandarli questa prox. notte fuora de questa prefata vra. Citate."
54MS, 2, no. 12.

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other places," the Health Magistrates argued, "there is presently no stain [of plague] whatsoever." Interestingly, the duke didn't see this information so optimistically. He answered the bulletins May 5:
. . we understand from what you wrote in your [letter] yesterday about the progress plague makes and of those who are ill, and we are much displeased with this. It appears to us that you have not applied every remedy and good provision. Thus we wish and charge you to summon the entire College of Medicine before you along with Maestro Benedetto da Norcia and all the court physicians, and even all the gentlemen (zettilhoiniui) elected to [stand guard] at the gates. And all of you together should consider and deliberate upon all of the best provisions for remedying this plague. We want to hear by this evening what you have arranged concerning this. It truly surprises us that you always assert that you need money to make provisions, etc., for you have not given us information as to the sums needed to make these provisions. We will make all disbursements as they appear necessary to us.55

The deputies were clearly in a difficult position, having to defend each step in order to receive money to operate and dealing with a duke who suspected that they were not performing their duties honestly. From their own perspective the deputies could argue that they were being cautious to a fault (in fact they were later faulted in just this regard). Even in the cases where the sick person's urine did not yet reveal plague to the physicians and where no external mark or signs had yet appeared on the individual's skin, the families were cautiously isolated or exiled. Insofar as they regarded medical counsel crucial to the outcome of plague control and believed plague to be spread by contagion, the duke and the deputies agreed in early
sSforzesco, CartcLqgio ilitcrno, 884, 5 May 1468:"havemo Inteso quanto ne scriveti per la vra. dil di de heri del progresso fa la peste et de quelli sono morti, del che ne havemo preso dispiacereassay, parendoneche per niente non se gli habii ad mandare de ogni remedio et bona provisione. Et impero voleimo et cosi vi commiettiamoche voy debbiatihaveretutto el collegio di medici da vuy et cosi MaestroBenedicto da Nors[i]a. Insieme con tutti li altri medici de la corte et Item tutti li zentilhomini ellectaper le porte et tutti Insieme debbiatipensareet deliberaretutte quelle bone provisioni che siano remediatoriead la peste. In modo che questaseranel mo[do] zonzere li possiamo Intenderequelladeliberationegli haveritifacta.Ben ne maravegliamodi factivostri che vuy sempre allegatiche se havesti dinariprovediesti, etc. Et dal altro canto non ne avisati che summiagli bisognariasiche avisatine de li dinari bisognarianoad fare queste provisione perche stipendolo faremo poy quello ne parreraessere el bisogno. Abiate[grasso]." At the same time Galeazzo Maria summionedthe lawyers andjudges to a debate, charging them to deliberatethe terms of the peace treaty he was negotiating in Rome. It is interesting that this well-educated young duke appearedto value professional advice highly.

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May. The deputies of necessity had to listen to physicians' reflections on individual patient cases and trust to some degree their final diagnoses. The duke, instead, could view all failures to contain the plague as failures in applying prescriptive epidemiological advice, not as data questioning the epidemiological model in use. Galeazzo Maria never lost his suspicion of the deputies' honesty and dedication to thorough plague control, as later examples will show. But for the deputies, the problem in May became one of dealing with the medical information that reached them. Two different sets of doubts could confound their simple causal synthesis that plague spread by human-to-human contact: cases falling outside the geographical boundaries the deputies accepted and cases obscuring the medical boundaries used to find a death unarguably due to plague. Uncontested plague cases usually, but not always, consisted of the sudden appearanceof a bubo in the groin or axilla, or death after only four or five days' illness. Thus, in order to defend their actions before a skeptical duke, the deputies and Secret Counsel had to shift the blame for procedure failures to the physicians' inability to give clear guidance, or to the noncompliant actions of private citizens who evaded public health controls. The other option before them, of course, was a serious reevaluation of the contagion model on which all their practices were based. Briefly the deputies entertained this possibility that plague was not spread by person-to-person contacts: "But if plague has proceeded from other influences, as from intemperance of the air, it will be necessary that the charity and grace of God work [with us]. We have heard loud murmurings about us and worry that some of these
complaints will reach your Excellency's ears. . . . We are not here

to displease nor to injure any living soul. We only stand by to do your orders and that which we know will be to the good health of this city."s6 But because doctors were at least partially committed to the notion of contagion as cause of new plague cases, abandoning belief in the efficacy of contagion practices would have left the dep56MS, 2, no. 19, 8 May 1468: "Se questi casi procedano da contagione non dubita v. S. che se gli fara bona provisione in modo la Cita se adiutara: Ma quando procedessero da altro influxo, o per intemperie de aere, bisognieria che la misericordia et gratia de dio se operasse. Nuy Intendemo se fano de grande murmuratione et existimamo che molti verrano a le orechie de v. Ex.tia a fare li rechiami et volerne sindicare dicenmo cossi, che nuy siamo qui per non fare dispiacere ne iniuria ad persona che viva. Solo atendiamo a fare quanto ne ha imposto V.S. et quello cognosceremo essere bene et salute de questa Citate."

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uties in an even more precarious position. Hence the deputies moved more committedly to document the contagious path of plague. The extent of the inquisitorial investigation by the health officers, done to document the contact transmission of plague, can be illustrated by a longish example. Giovanni Catelano reported a new case of plague on the morning of 7 May. Antonio da Robio, a nineteen-year-old youth who worked in the barber shop of Giovanni Pietro de' Mori, fell ill with a high fever, no "signs" yet apparent. The shop in Piazza della Corte was across from the window of the Maestri dell'Intrate (customs officials), where a few cases had occurred. 7 This discovery was a relief to the deputies because it explained a case that otherwise demanded a very cautious, measured report. Young Antonio actually lived elsewhere in the city, across from the house of a Baldesare Capra (near the church of S. Simplicianino; see map). "Until now," they admitted, "we couldn't find out where he had acquired the disease," and they suspected that he had bled or had otherwise come into contact with an infected person. Despite their best efforts they had not been able previously to trace the path of plague from person-to-person. 8 The area near the barbershop was clearly infected: Lucia, the fourteen-year-old daughter of a certain Giulielmo di Teoldo, died there this day. Catelano or his superiorsjudged this a case of plague even though Lucia showed no external sign whatsoever, merely because she had gone into the Cinque Vie and talked with people who subsequently fell ill with plague. Yet a third plague death was explained by careful investigation of her itinerary, allowing the deputies to conclude that the Cinque Vie was still the principal focus of plague infection in the city. Contagion was reaffirmed along with the geographical
57Ibid.,no. I5, 7 May 1468. The health officers and customs officials were traditionally adversaries duringplague times, the latteroften trying to postpone declaration of plague because it would reduce income and commerce to the city. In the view of health officers, the delays put the community at further risk. See Albini, 97. 58Presumably the deputies were informed of this new case on the day they wrote, which makes the "until now [fin qui]" statement problematic. The next day (MS, 2, no. I6) they wrote that the barber[Antonio?] "ha butato fora el signale" but that "so far [fin qui]" they had not tracedthe origin of the case. The text is otherwise ambiguous. No reportof Baldasare'sillness (if he was ill), or his death (if he died) survives. If he was not ill, Baldasarecould be relatedto this case merely to secure the location or perhapsbecausehe was socially important. The other case reportedthis day, in this letter, mentions the immediate neighbors of the infected, Count Giovanni Bonromeo and banker Marco da Galara(MS, 2, no. I5).

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concentration: "only one new case appearedtoday [14 May], which we believe was produced by contagion, because it occurred in the
infected district. "59

The deputies' letters cheerfully affirm the wisdom of their procedures, revealing to the duke the actions that they had taken in the immediate past, how the evidence confirmed their working contagion model, and ending with assurance that they would continue to do everything possible to arrest the progress of plague. Insofar as they reported "evidence" for contagion buried in the cases on which action had already been taken, they had been withholding from the duke evidence that didn't immediately fit the pattern of expectations. Cases that eventually became explicable were reported at length. In all of this, it is not clear whether the deputies were deceiving the duke or themselves. Physicians making the diagnosis with which they all had to contend became critically important information, and, as we shall see, the health commissioner, Hector Marchese, claimed that it was at just this time he began to worry about the process of medical diagnostics. Beginning in midMay, Hector began to send the duke yet another copy of the daily death and illness report, so that the duke received three or more nearly identical bulletins each day! At this point the deputies also began to send separate reports of new cases, distinct from the death reports. Responding to the rather dramatic increase in the number of official plague cases reported, the mass exodus began around 8 May. At this time two little girls fell sick with plague, daughters of one Cristoforo da Cazeniga, who lived in the district of the Porta Vercellina, the neighborhood of S. Pietro della Vigna, the parish of S. Maria al Circo. They lived near enough to houses infected back in March that no worry presented (see map). And two others died in previously infected houses. But Hector and Catelano had one more case to explain. The parish elder in S. Maria Pedone reported ill a woman who was interrogated unsuccessfully. Not only could Marchese and Catelano find no evidence of the path of contagion, the woman died during the questioning, redoubling their suspicion that plague was the cause. A personal advisor to the duke restated the health deputies' message in a way unburdened of contagion theory: "things are not without danger now that [the plague] pops up
59Ibid., no. 28.

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in so many different places. . . . Most of all you must protect yourself."6o It was a message Galeazzo Maria related to his mother in

early June, begging her not to stay in Cremona, where plague behaved the same capricious way.6' It was also a message that questioned the spread of plague by contagion alone. But at this time Galeazzo Maria was preoccupied with his ambassadors' negotiating a peace treaty in Rome and with upcoming wedding plans, so his personal secretaries and servants concentrated more on the problems created by flight from the city.62

Missing links in the chain of infection were a type of problem Hector Marchese and the health magistrates had to explain defensively to the duke, for the latter would conclude that officials were simply not diligent enough. In turn they tended to fault the physicians who could not seem to diagnose plague early enough in its course for implementation of appropriate precautions. From the physicians' perspective, it was sometimes difficult to diagnose plague even after a person died. For example, atjust the time panic was greatest, on I6 May, Constantina, the five-year-old daughter of Maestro Iacopo da Firenze, died with "many malignant worms, and abdominal swelling and pain, after a six-day illness." Iacopo was both a surgeon and an anatomist, and he had worked with Catelano in the great plague of I45 as official physicians to the Sanita. Thus he, too, had extensive experience diagnosing and treating plague. His daughter died of an illness common among young children. But on 31 May, Ambrogio, twenty-year-old servant of Iacopo, fell ill with pestilential fever, a bubo in the right axilla, and with a profuse nosebleed, according to the judgment of Iacopo himself and Maestro Dionysio de' Cerruti, another surgeon. This case was unavoidably listed among the new "suspicious" cases this day, even though the deputies made an exception and allowed the
60Ibid.,no. 21, from Giovanni Giapanoto the duke: "non me paresiano senza pericolo vedendola [peste] saltarein tanti diversi lochi. E pero fidelmente ricordo a V. S. prima el conservarela persona da la quale depende la universale salute, non solo de questa sua patriama de tuta Italia." 6'Ibid., no. 354. 62Ibid., no. 22, FrancescoMaletesta, io May, worries that citizensfleeing from Milan to other cities in the ducato will bring plague with them; ibid., no. 21, Johannes Giapanus warns the duke that he should consider envoys from Milan, as well as other plague spots, dangerous, and that it is important for the duke to preserve his own health, "da la quale depende la universale salute non solo de questa sua patria ma de tuta Italia"; ibid., no. 29, Giovanni Simonetta tells the duke 5 May that none but the "poveraglia" remain in Milan.

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household to remain in their quarters, while they whisked away all of the other suspects. Catelano added to the report, "But I am amazed that the urines are laudable in this case; I expect, however, the appearance of a rash [morbilorum, or measles]."63 Infections occurring in the houses of physicians inevitably evoked some of the flexible rhetoric in plague diagnostics, but magistrates' own criteria often overruled the physician's. For example, a servant of Maestro Girolamo da Lode, longtime member of the college, on I8 May was ill with an "aposteme" in his right groin and had "spasmotic tetanus with parafrensy."64The boy was at death's door, and the deputies doubted that this could be explained any way other than plague, for another boy in the household had recently died. "For greater security I [probably Hector] have had the house closed up, and that which he [probably Girolamo] wants to hide by alleging that these are not suspicious [cases] soon will be clearly seen. This is not a new case because he [the servant] was contaminated, as your Excellency can see."65 The duke's personal informant, Giovanni Giapano, spelled out the path of contagion, citing the earlier death fifteen days before as a plague case "even though he [the physician] denies it" and because the physician went to visit his father at the hospice "il Seraxino," near the castello. The physician was ordered to stay in his house and had done so, at least through one whole day, "even though he has tried [to escape] many
times . . . saying that this is not a suspicious case." Giapano also

enlarged upon the duke's theme of mendacity among public officials, asserting that Maestro Girolamo had not declared this illness in his household, concealing it for several days. Persuaded, probably by Giapano, that the physician's motives were malicious, the

frenesia, moriturusiam iam." Hieronymus de Casetis de Laude [Lode] matriculated

in the College of Medicine 12 November 1432; see Bottero, 112. Bianca Maria was informed of the servant's death as well; see Sforzesco, Cartcggio interno, 884, 22 May 1468, ferring "contaminatio."

'3MS, I, no. 364. '4MS,, , no. 36, Deputies to duke: "Antonius famulus Mri. Hyronimi de Laude, [14 years old], infirmatur cuIm aposteme in coxa destra et spasmo tetano cum para-

Giovannida Petrasancta to BiancaMaria.Giovanniavoids the word "contagion," pre5Ibid.:"Permagiore securezal'ho fecemo serrarein casaet cuossi quello coleva occultarecon allegarenon fuosse sospecto hora si se apertamentedimonstrato. Questo non e caso novo per essere luy contaminatoin quelo Inodo puo vedere vra. Sig[nor]ria."

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deputies said that they had decided to send Hieronymo and his entire family to S. Gregorio, the lazaretto, "where he can tend to the
others."66

The Boundaries of Contagion Practices By late May Galeazzo Maria began to question the rationale for the contagion practices that health officers defended. The response of an old, faithful servant of Galeazzo Maria's father and grandfather may have been prompted by the duke's growing concern: "I don't recall ever seeing such ordinances [during the time of] your uncle, Filippo Maria," Antonio Canobio wrote to Galeazzo Maria on 25 May, but there were more recent precedents.67By earlyJune, the duke began to question both the model of contagion and, again, the honesty of his deputized officials. After a rash of cases that the deputies likened to a flame,68Galeazzo Maria had ordered a full inquiry into the causes of plague, summoning (from a safe distance) the opinions of the physicians in the College of Medicine, from his deputies and Secret Counsel, and from Hector Marchese himself. 69 Two things worried the duke: was not the plague contagious? and, if it was, why was the trail lost in May? The college responded with a consilium taking into account Milan's relation to astral events that but spring blaming the excessively humid fall and early winter for the appearance of acute fevers, though without any explanation why transmission of the disease progressed steadily through the spring. Hector Marchese, aware of the medical opinion, also an''Ibid., no. 38, 19 May 1468. This story becomes still more complex. On May 25 (no. 47) the Deputies wrote that on the ninth of May a boy (ragazo) of Magister Hyeronimo went to the hospice of the Sarayno near the castello, and "we, as is our custom, saw that all those in the household were promptly [statiim]taken to Sancto Gregorio, and thus it was done." This isn't quite true. They next say that there were "other pensioners" in this house who remained separated from the infected, so, cautiously, they were quarantined in the house so that they could not get out. For fifteen days they were hale and hardy [sani et salvi]. Nevertheless, two little girls died the previous night (May 24), so all the rest of the household were shipped off to S. Gregorio. The deputies were offering the best possible interpretation of their actions. 67E.g. Ibid., no. 48. That exemplar no longer survives with the letter, nor have I been able to locate Galeazzo Maria's letter specifying the procedures that troubled him. 6'Ibid., no. 57, I June 1468. 6'He demanded the opinion of the College of Medicine in early May, but the convocation probably did not take place untilJune. The undated consilium appears in MS, I, no. 26, titled "Responsio Collegii Phisicorum et eius apparere super interrogatione facta per Illustrissimum principem vestrum circa processum pestis Initiantis ad multum susceptura [sic] sit incrementumn dicitur ut infra."

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swered the duke's request of 2 June, acknowledging the problem with his own strict adherence to contagionism:
During the first wave, about the fourteenth of March, in S. Vittore, and following house by house from those of Lampugnano, I reflected from time to time about the process and concluded it must be by contagion [that plague spread]. This was until the third of May, when the household of Scaramuzia Visconti was infected. From there it proceeded into diverse houses and parishes, and I lost the path of contagion. And since I anticipated your question, I went around with Catelano and other physicians of the college, visiting the houses with them so that I could understand what was happening. I wanted to know why so many [cases] were seen by a physician on the day that they first became ill, but the physicians, not fully recognizing their illnesses, held the [news] two or three days before declaring the case one of plague. The answer I had from Catelano and the others was that in the beginning they didn't know, and couldn't know, because they looked only at the urine: they had neither visited nor touched [the sick], nor do they visit or touch them. Thus some had evidence of acute fevers for which, in a short time, the urine later changed and showed the case to be pestilential, and then they had to change their notification. At this point we [at the office of the Sanita] went to visit the ill person and decide the truth about who was plague-stricken. Now as to the cause [of plague] they agree that we should doubt the influence of some planet or other. But, your excellency, even until today I do not lack either the conviction or the hope that, God willing, [our approach will work].7"

Marchese then cited his experiences with plague in 1464, 1465, and in the previous year, expressing faith in the efficacy of current plague procedures, if applied diligently. During late May, he and the other health magistrates had increasingly shifted the blame to
70MS, 2, no. 70; "mediante dal primo asalto fece a di xiiij di Marzo a Sancto Victore attine6 [?] et sucesive in casa di quili da Lampugnano et procedendo di casa in casa di tempo In tempo, ho miso la mente trovava et Intendeva il processo essere contagione per fino al tertio giorno di mazo, quale fece lo asalto in Casa dil quondam scaramuza viceconte, poy procedendo in diversi loci et parochie ho perso la strata di la Contagione. Et io como quello voleva intendere piu inante me sono astretto piu et piu volte con il Catellano et con alcuni altri medici collegiati digando io verso di loro donde poteveno Intendere procedese questo, perche molte case quale erano nele [?] mane di li suprascripti medici non havevano Inteso le loro malatie et teneveno nele mane duy et tri giorni uno amalato possa ala fine si ritrovar pestiferi. La risposta ch'io haveva dal Catellano et da loro e questa: che neli principii loro non cognoseneno ne poteveno cognosere sopra le urine perche che non visitaneno ne tochaveno ne ancora tochano ne visitano, dicono havere ante nele mane alcuni di alcune febre che in pocho di tempo se cambianeno le urine et monstraveno subiugale et pestifere et li remeteveno nele mane di lo officio donde havemo che visita et chi tocha ad dicernere la veritate. Et questo concoreno et dubitano non sia Influentia di alcuni pianeti. ..."

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physicians' tardy diagnoses, further emphasizing the duke's previous conviction that the contagion model best fit the facts.7, EarlyJune brought a reprieve in the number of new plague cases, as it usually did in Milanese plagues.72 Galeazzo Maria could have seen these events as a measure of the success of public health intervention had not his adherence to contagion practices begun to waver. As he had predicted, his mother became ill in fleeing Milan for Cremona. She wrote 30 May to praise his powers of divination. Responding on 2 June, the Duke argued that his deduction that she would become ill was only logical due to the rigors of the carriage trip. As to his prediction that Cremona would soon have plague, Galeazzo Maria explained: "it seems to me almost impossible that you would not carry it there," bringing such a huge retinue. But he avoided altogether the delicate issue of contagion, which could implicate some member of her household. Galeazzo Maria received letters from her doctors that she was improving but cautioned her to be especially careful, "because your every illness is my illness." In other words, this was a period in which Galeazzo Maria was dependent upon what the good doctors could do, and a time in which he was abandoning hope for a wedding in Milan. Over the summer, the medical authorities vacillated as much as did the duke on the verdict of contagion. When a burst of new cases confounded all efforts at diagnosis and control, the doctors concluded that the hot, humid weather and bad astrological signs meant plague could not be extinguished. By i July, with another break in the succession of new cases, the deputies took hope that "these physicians are beginning to say what they didn't say before, that the plague has been due more to contagion than to corruption of the air."73 The deputies, for their part, held fast to the contagion
7'E.g., Saturday, 28 May, MS, I, no. 359, from Hector: "Ambrogio dei Platti, aged 40, fell ill on Tuesday about the 20th hour, with fever and severe headache, etc. In fact, Tuesday about the same hour a carbone appeared on his right neck near the chin; and he was in a house contiguous [with a plague house]. [Now dead] with black measles, the judgment of Catelano. And today is the notification." MS, 2, no. 21 I, the same day, the deputies list the new cases, repeating that the victims were infected Monday and Tuesday, "but we were not told." 72Albini, 166-67. The peak months of mortality in normal years (from 1452-1480) were the hot summer months of July and August, the lowest monthly mortality in June. Aggregating plague and other epidemic years. the June nadir is even more pronounced. 73See MS, 2, no. 103 (17 June); and ibid., no. 148 (i July). Both letters are from Giovanni Simonoetta. The operative part of the latter text reads: "et spera che la cosa

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"theory," even when having to acknowledge severe operational difficulties. When Catelano's servant fell ill with plague in early August, the deputies decided that they could not do without him, and informed the duke that they simply could not adhere to contagion control in this case. Catelano would set out early in the morning and return late each night, as he always did, though he agreed to change his garments often, use discretion, touch no one, and not spend much time with any one person during this ambient quarantine. 74

When he began to doubt that contagion alone explained the plague, the social consequences of contagion practices became less tolerable to the duke. Apparently Galeazzo Maria had heard that Catelano and Marchese were to blame for excesses, because the deputies begged him to do nothing rash:
We respond, both to clarify things to Your Excellency and to satisfy our [anxieties].First, about the plague: that Catelano and Hector often seal up houses that are really not suspected, because of some hope to profit. This is unlike them, there could be none better than these two .... If there is anyone to blame it should be us, not Catelano and Hector, and by being silent we could do an enormous injustice .... We must tell Your Excellency that all the cases occurring so far have been denounced to us, and we know with certaintythat Catelano has faithfullydischargedhis duties. All
but one of those judged "suspect" have turned out to be true plague. In any dubious case, they have returned two and three times to visit the ill.75 bene maxime perchequesti medici dicono altramenteche non dice[the plague]passara vano prima:et che el male e stato pii tosto per contagione che per mala dispositione de aiere [sic]." le casenon sospecte, per aviditatedel guadagno:che non conoscemo spessefiatesarrare questo in loro: ne niuno puo meglio attestarequesta cosa de nuy che siamo sul facto.
Et nuy intendendolo mal voluntiera il comportaressino che loro ne altri officiali sopra cio facessero cosa alcuna mancho del debito suo. Et quando si ritrovassi questo essere
74MS, 1, no. 2, 6 August 1468. 754June 1468, MS, i, no. i: "Et primo a la peste, che il Catellano et Hector fanno

vero, ne reputariamoche ogni defecto et manchamentofuosse in nuy et non d'essi Catellano et de Hector, che tacendo consentisimo ad cuosi enorme inganno, overo che fuossimo si pocho diligenti che non intendesimo li excessi suoy. Ma in vero li trovamo si neti et si immaculati in questa cosa, che non li cade reprehensione alcuna, pero non fanno uno yota senza nostra deliberatione. Avisando v[ostra] S[igno]ria che per li casi occorsi fin a hora denuntiati qua a nuy: comprendimo chiaramente ch'esso Catelano ha facto fidelmente l'offitio suo, pero tutti quelli Iudicii n'ha dati per suspecti isque ad ungtlemli hanno trovati esser veri. Et quando gli accadera un caso dubioso gli ritornava

due volte et tre ad visitarlo et sempre n'ha [?] chiaritode la verita. Le case infecte im-

ponevamo che de nostro mandamento fuossero sarrate ne de cio il Catelano se nai non specta a luy." intrometuto-perche

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The deputies, not Catelano, then sealed the houses, and for additional security, the deputies quarantined all those who had had any dealings at all with the plague victim, operating with the counsel of two other well-respected physicians in the college, men who taught at Pavia and were known to the duke.76 They deemed their defense of Marchese and Catelano "extremely useful and necessary, for without them we would have enormous difficulty finding their equals. Neither in capability nor in experience could there be two so suited to this job." One of the problems surrounding the spread of plague in June could scarcely be attributed to procedure failures by the Milanese health authorities. Plague-free cities in the duchy would have to ban travel from Milan, and thus compromise the whole structure of all but the very wealthiest citizens seeking a safe refuge. The duke had in effect admitted privately that Cremona was infected by the entourage of the duchess. Pavia was still safe, but travel from Milan would have to stop.77 Cicco Simonetta, the duke's secretary, realized how much more severe the restrictions had to become in order to arrest a contagious plague. On 3 June he advised the Secret Counsel: "Because at Cremona and in Parma, the plague has recently appeared in several different houses, we remind you, and want you, to renew all [the precautions taken] at the gates, bridges, passes, and other necessary posts, such that those from these cities, or any other infected places, cannot come to Milan, nor those from Milan with other suspected or unsuspected. Because [doing so] would be like extinguishing a fire one place while throwing dry wood on another."78The Secret Counsel compiled but urged the duke to adjust the regulations so that trade was not completely stopped: "About the infection of Parma and Cremona, we also have heard that some contagion has appeared, but not very much." Banning these places entirely, they argued, would be very damaging to the customs duties, and it would rapidly extend to the entire duchy. There should be something less restrictive than the ban. "Nevertheless, we will certainly not accept anyone from these places who does not possess a pass from their officials certifying that [he] is healthy and free from all suspicion." They would write the duchess that passes would be a necessity, eitherfrom the officiali
76'See below, n. 83. 77MS, 2, no. 66.

7XIbid., no. 65.

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delle bolette or from her, and if conditions worsened in either city, travel and trade would cease.79Effectively the counsellors were educating the young duke about the economic limits of contagion control. Another kind of problem that could not be blamed entirely on the deputies was the popular unrest growing among those trapped in Milan. The duke's personal servant, Giovanni Simonetta, assessed rumors of the duke's lack of charity and mercy as coming from malcontents "who have nothing to lose." There were a few overly arrogant, imperious individuals among the officials but there was more to fear from occult plague spreaders:"It is true that until now a few who have had plague in their houses were ignorant of the fact and didn't recognize the disease until the very end, and that they went around the city without any respect for the danger
... but then some fled, leaving houses abandoned." Simonetta

thought the latter action should be punished severely and recommended irrevocable seizure of their household goods.80 Still other problems plague caused could not be blamed on the deputies' shortcomings. Galeazzo Maria must have realized that even if the plague were brought under full control inJune, wealthier citizens would not return in time to host and house wedding guests.8' Nonetheless, he did assign properties belonging to the Misericordia to a cavalier from Calabria. The deputies had to remind him that they felt bound to the conditions stipulated in the will donating the property for aiding the poor, and so they had moved in people, horses, and cattle, upsetting the duke's guest considerably. Here the duke had to give in, for, without the help of pious places and lay confraternities managing the daily relief efforts, all plague controls would fail.82 By August the wedding had past, with only token celebrations in Milan. To retain physicians other than Catelano and Dyonisio,
79Ibid.,no. 355, 4 June. The letter to the duchess, dated the same day, is in ibid., no. 68. The Consilio Secretoalso promisedto notify all the appropriate guardsof these decisions. In ibid., no. 74, June 6, BiancaMariarepliedthat she would happily comply with the new, moderate restrictions. 8Ibid.,no. 67. Symonettamay have been alludingto the caseof Antonio Carissimo;
see ibid., nos. 57, 59, and 97. 8'Sforzesco, Carteggio interno, 884, i6 June, Giovanni Giapano to the duke. 2, no. 143. The duke instructedthe Consilio Secretoto house lord Scaramuzia 8ZMS,

in suitablequarters,and they assignedpossessionsof the confraternity.See also Albini,

82.

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dedicated doctors to the Sanita, Galeazzo Maria would have to have begged or ordered collegiate physicians to stay, much as he had to threaten guards and provincial officials who tried to abandon their posts. Even inJune, the college physicians who reconfirmed the diagnoses of the deputized physicians found excuses to leave. 83Areas where the duke could not assert his personal will, such as Novara in lateJune, posed considerable threats to the best executed of provisions. The servant sent to Novara was dedicated and well informed how to exercise plague controls, but he had to advise the duke that "this city is surrounded by many plague-infected lands. And I have real doubts about this city because of the negligence and avarice of these citizens. Never in my life have I seen greedier men; they make little or no provisions for the city and every day they are further infected . .. they make my soul cringe in my body!"84 The Epidemic of 1468 in Wider Perspective From all the surviving notices it appears that this plague in Milan was relatively minor: never were there large numbers of deaths, as had been the case elsewhere in the I460s. The notices are incomplete, but during April through July no month lacks the entries for more than three days. During those months, May and July were the worst periods, with totals of a mere I 50 deaths (from all causes) per month. The plagues of 1450 and 1483 were the two lethal ones in Milan's history during the late fifteenth century.85 Nearly all of the physicians active in making the diagnoses of cause of death in
1468 were alive well into the I470s. The relatively slow progression

of new cases allowed the health officials both the time and the incentive to explore the operational limits of contagion theory. Admitting any other theory than the contagion model implied the charge that the duke and his men were not acting with Christian

'3Sforzesco, Carteggio interno, 884, 23 June. Maestro Symone da Mazenta and Maestro Matteo da Busti, deputized by the College of Medicine to serve as backups, left the city. Both asked to be excused from further duties in the city. X4MS, 2, no. 147 ("me fanno crepare l'anima nel corpo"). X'Albini, I62, finds a total of 648 deaths this year (I count only 623), but the records ofJanuary-March are largely missing, and many other gaps exist late in the year. By contrast, the surviving, incomplete records of I451, for only three months at the end of a plague, include 2,515 names; in 1483, 4,179 names are recorded, and in 1485, the year after the great plague (no records of it survive), partial registrations number 8,598 deaths.

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charity in a tragedy that was either inevitable, ecologically and astrologically, or simply an unknowable aspect of God's will. Mistrust of the officials' motives could breed dissension and lead to political disaster. Full and early knowledge of plague infection brought the risk of contaminating the men responsible for making the diagnosis, just one of the practical medical considerations of managing the epidemic while adhering to the contagion principle. These extraordinarily rich letters allow us to explore the theoretical basis for making the original diagnosis of plague, at least at the bureaucratic level, and they present a distinctive impression of early epidemiological reasoning in the face of an epidemic. This Sforzadriven inquiry is more elaborate and self-conscious than mere coping with accelerating death rates, and the resulting correspondence provides detail quite unusual this early in state plague control. Not for another century would the health boards of other cities leave comprehensive daily record of their deliberations. Just as the process of plague control in 1468 involved partially negotiated agreements between health officials, physicians, and the "central government" --the duke and his servants-each of these three groups could be seen to have approached the problem with certain legacies toward what "contagion" meant when applied to plague. Much of this has been discussed above, but it is puzzling that the duke was willing to side with the physicians against his own officials and Secret Counsel who claimed to be following his instructions to the letter. One letter hints the duke's irritation with the College of Physicians in Pavia, but it may have concerned issues other than plague. 6 Even as the plague receded, Sforza was far angrier at the deputies and Hector than at any physician. September 2 he wrote to Hector personally: "At a little church called S. Biaso
... a young boy was found dead this morning, who just yesterday

was said to have been moving about. And because he could have died from suspicious causes the captain here ordered that he not be buried without being seen. We want you to send someone experienced to do this right away, who should then relate his findings that to whomever our captain sends. I am warning you [Avisandote] at Pillastrello, which is just overlooking this road and across from the church, there will be someone watching and informing [us]
86Sforzesco, Cartce~Qio inlterno,883, 7 August 1468. Galeazzo Maria didn't like their talking about him or criticizing his actions.

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about everything. "7 And again late December the deputies had to

respond to Galeazzo Maria's wrath:

Today we have a letter from your Excellency, which we have understood all too well. Your Lordship judges that the last occurring cases were produced through conversations of people and touching goods of infected houses, not well cleaned and scoured, and that they cannot have proceeded from some other fault [culpa] or contagion. We advise your Excellency that this cannot have happened in this way, for all of the houses and infected places, except the very last one which was on the i6th of this month outside Porta Nova, were fully cleaned and purified. Nothing has transpired without great diligence, consideration and care, the effects of which are demonstrated by those returning from S. Gregorio and even those who remained in their own houses, which were afterwards cleaned. By the grace of merciful God, not one house has shown any peril or illness. It is not through our fault nor our oversight that the last cases have occurred. . . .x

Of course it was no one's fault that plague did not faithfully behave like a contagious disease, because it is not normally contagious from person-to-person. A rat- and flea-borne disease, plague can produce contagious plague pneumonia, contagious because the airborne droplets the patient coughs out are highly infectious. This usually occurs, however, after the victim becomes severely ill from the initial infection. Similarly, opening or lancing a bubo may liberate organisms, passing the disease by touch. But in most bubonic plague epidemics the appearance of contagion is accidental.89 Health officials in Milan were certainly empowered in their enforcement of contagion practices, aided by strong, supportive dukes in a way "republican," or rather oligarchical, governments elsewhere in northern Italy would not permit, because of the damages to trade and to their strategies for flight from the city, the main form of personal defense. But in 1468, Galeazzo Maria effectively wedged his own daily controls between the physicians' and the health officers' views of plague. In these negotiations the health magistrates obviously felt that they had to account and defend every decision, small or large. They articulatedtheir position successfully, whether or not anything they did changed the course of plague in the city. In 1476, the next time plague threatened Milan, Galeazzo Maria was assassinated, but the same deputies in charge in 1468 took over
X7Sforzesco, Cartcggio inter,o, 885, 2 September 1468.
'XMS, 2, no. 209, 21 December.

'9See Carmichael, I986, 5-9.

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virtually where they had left off, now extending their personal and aggressive plague defenses to the ducato cities. A month before the murder, Giovanni da Pietrasanta, commissioner of the duchy's health defense (Hector Marchese was still commissioner for the city of Milan), wrote to the duke that the few identified cases of plague had been brought under control. Since they were not needed in the city, Giovanni and Hector left for the town of Chiastezo, "along with others as we deem necessary," in order to snuff out the sparks of plague. "And we want you to understand that we will do and order everything necessary to eradicate this venom . . . because otherwise, we will never be secure; unless, as I have said, this bitter and cruel venom is extirpated to the tips of the roots." This meant extensive inquisitions about contacts, and burning all goods and belongings of those diagnosed with plague.90With Galeazzo Maria's death the health magistrates became the vessels of tradition regarding contagion practices, in a way that the physicians, eager to escape the physical management of cities and towns during plague, could never be. Individual physicians, such as Giovanni Catelano, who were willing to stay and serve the plague-stricken, may well have explored the practical challenges contagion models offered in diagnosing disease.9 But most physicians of the late fifteenth and early sixteenth centuries would have to explore these concepts devoid of intimate contact with plague. Richard Palmer brilliantly argues that the health magistrates, especially when they carried out a role of public health surveillance and administration in years between the major plagues, were the ultimate source of innovation in contagion practices in Renaissance
9See MS i, no. 10, 27 November 1476. A letter from Giovanni Nicol6 dei Berezonzii (ibid., no. I I) confirms the extensive destruction of property with the outbreak of Pavian cases of plague. 9'One of the most striking examples I have found is that of Catelano, in the midst of the great 1485 epidemic, arguing to both the health officials and whoever among the duke's (now Ludovico il Moro) staff read the notices that pleurisy was a specific disease and it was contagious. MS, 4, no. 739, contains one of these entries, reading "Reynaldus de Pergamo, 47 years old from the parish of (San) Eufemie, fell ill about Friday with true pleurisy on the left side." Catelano judged the case to threaten contagion ("et periculosa de contagii") because his wife and one of his daughters died in the previous days of the very same cause, "such that I judge these pleurisies should be considered another epidemic just as pestilence" ("dixi huius pleureses altera epidimia atque pestilentia considerabitur"). The deputies merely labeled this a probable plague death, coming as it did from a suspected house.

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Venice.92 Prior to establishing a permanent health office in the I49os, the Venetian magistrates consciously borrowed Milanese

methods during crisis interventions. The plague controls elaborated during 1468 in Milan and reiterated in the I470s were observed and copied by Venetians. From Milan they could hear a strong and sure voice, unequivocating as they articulated the most effective means of plague control, a voice unbroken by the powers of later Sforza dukes. The Milanese practices during epidemics would lead eventually to the most brutal-if in some sense logical-expression of an unqualified contagion theory: prosecution, persecution and execution of the untorior plague spreaders in the 1630 plague. Late in the sixteenth century, after the most severe plague ever to hit Milan, the plague of Saint Carlo Borromeo in 1576, Milanese physicians linked their commitment to contagion theory to the possibility that plague could be carried in the form of unguents and salves, spread on the doorways, walls of the city, benches of the churches, and elsewhere, to facilitate the spread of plague.93By 1630 the Milanese, virtually alone among northern Italians, were prepared to identify and prosecute those who transmitted the plague maliciously. It was a bitter consequence of a politically privileged contagion theory in the search for effective plague control. Much has been made, by myself and many others, of the behavior of true plague in the early modern cities. Are plagues of this period dominated by the lethal action of Yersiniapestis in a human population, or do the economic disruption, the chaos, and poor personal and public hygiene push the death rates far higher than a killer microbe could unaided? Did plague change over time, becoming a more (or less) brutal disease than that seen in twentiethcentury experience? Were these plagues actually contagious? If eyewitnesses insist that the identified cases of plague evidenced contagion, is there any reason we should doubt that precious testimony? In this exposition of the reasoning processes at work, at
92Palmer, 1978. This masterful dissertation has unfortunately never been published, though it is cited repeatedly in most recent works devoted to the topic of plague in Renaissance Italy. I am very grateful to Palmer for permitting me to see this dissertation and for discussing these issues of contagion theory in the fifteenth century, for the ideas he provides were the most crucial to this study. Portions of the thesis are published in Palmer, I986 and 1979. 931On the plague of I630 and contagion theory and practices that led to the persecution of Itiori, see Preto; Nicolini; and Canosa.

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the clinical and epidemiological levels, by conscientious administrators and dedicated physicians, I have suggested that both a "yes" and a "no" could be given to all of these questions. In some ultimate, reductionist sense the microorganism Yersinia pestis existed illness it caused human in the fifteenth century as it does today, and and death. But the disease of plague, the associated practices of diagnosis and defense, and the contagion theory to govern its control, were all socially constructed responses to some deaths and some epidemics, not necessarily to Yersiniainfection.
INDIANA UNIVERSITY

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