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    Renaissance Society of America

    Contagion Theory and Contagion Practice in Fifteenth-Century MilanAuthor(s): Ann G. CarmichaelSource: Renaissance Quarterly, Vol. 44, No. 2 (Summer, 1991), pp. 213-256Published by: The University of Chicago Press on behalf of the Renaissance Society ofAmericaStable URL: http://www.jstor.org/stable/2862709

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    ContagionTheoryand ContagionPracticein Fifteenth-CenturyMilan*by ANN G. CARMICHAEL

    HENUSEDTO UNDERSTANDAND COMBAT he spread of bubonicplague, "contagion" is not avery helpful term. Plague is eco-logically a complex disease transmitted from rodents to humans viafleas, and human-to-human passage of the disease is uncommon.Moreover, humans do not form lasting immunity to plague andcannot maintain the microorganism in human populations in theabsence of infected rodents and their fleas. There can be no "Ty-phoid Mary" figure in the passageof plague. Nevertheless, popularhistories of late medieval and Renaissance Europe, as well as spe-cialized histories of medicine and of public health, champion theemergence of contagion theories and practices based on the accep-tance of contagion ideas, as the progressive edge of European de-fenses against recurrent plague.While contagion theories do not adequately account for the ac-tual biological occurrences of plague in humans, the evidence thatsurroundedthe earliestproduction andelaborationof such ideas cantell us much about the social context in which they first appeared.What observers found important and what explanatory modelsthey accepted at all stages of the diagnostic process is as revealingof early modern experience during epidemics as is discussion ofwhat actuallyhappenedto causeillness and/ or death from the mod-ern medical point of view. In "seeing through" (the literal mean-ing of"diagnosis") an ill person's observable "signs" and report-able symptoms, medical and lay witnesses to sickness and death at-tach meanings reflected, in part, in the naming of a disease, a"cause," or a particularlydisturbing event or sequence of events.

    *All manuscript materials are drawn from Milan, Archivio di Stato, and I am mostgrateful to the staff archivists who helped me in locating these materials. This paperwas originally presented at a conference on the History of Disease sponsored by theFrancis Wood Institute at the College of Physicians of Philadelphia, March, 1988. I amgrateful for the comments and suggestions of Ellen Dwyer, Arthur Field, Helen Nader,James C. Riley, Charles Rosenberg, Steven Stowe, and especially Katherine Park forguiding my revisions of the original paper. This research was supported by the Na-tional Endowment for the Humanities, #RH2o835-87.'On the standards of diagnosis see Ballester; Lockwood; and Siraisi.

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    RENAISSANCE QUARTERLYIn this way, social historians of medicine would argue, a disease is"socially constructed."The diagnosis of plague, for example, involved a process of dis-tinguishing some illnesses and deaths as cases of plague while dif-ferentiating these from non-plague cases. Some part of the set ofrelevant criteria were obviously medical, some epidemiological,leading a diagnostician to say that a case was one of plague becausesome important criterionwas fulfilled and could be verified by any-one observing the evidence. Of course, to agree on the name or di-agnosis observers had to share the same assumptions about whatcould be concluded from that evidence. A larger meaning for "so-cial construction of disease" might make far greater claims than Ishall here as to how the assumptions (e.g., theories) were agreedupon and what kinds of evidence were allowed or discounted. Inthis more limited study, I shall examine the relations drawn be-tween evidence and assumptions in the diagnostic process and de-scribe how differently-oriented persons in authority wrestled withdifferentexperiential data that they gathered by managing, day-to-day, the spreadof plague in a city. Many struggled to link that ex-perience to the concepts invoked by their use of the supra-diagnostic category, "contagion," which had different meaningsfor different diagnosticians.I describe the course of a relatively minor plague, that of 1468,in a relatively large urban center, Renaissance Milan. Most of theelaborate discussions about plague contagion andpublic healthcon-trols based on that assumption postdate the mid-fifteenth century,so I am also describing a relatively early point in the political andintellectual debates about contagion-based plague control. Becausethe Milanese were wrestling with the formulations of contagiontheories and concepts generations before others did, I shall neces-sarily have to preface description of the 1468 plague with a reviewof Milanese practicesand attitudes to plague before this time. Oncethis groundwork is laid, I shall provide a detailed description of theideas and assumptions of medical witnesses, public health author-ities, and the ruling elite during this particular plague.Death by itself had become a meaningful social event to Renais-sance Italians, who first began to keep records of mortality duringthe late fourteenth century.2 For the Milanese, the assignation of

    'See Carmichael, 1986; and Cipolla, 1972.

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    CONTAGION THEORY AND CONTAGION PRACTICE 215medical cause to death registrations was obligatory after the mid-fifteenth century. All individuals over the age of two at death, inallyears, whether or not plague occurred, had to be assigned acausefor death, as the records surviving after 1452 amply testify. Theserich data that Milanese records provide suggest that it is pointlessto debatewhether medical men or public health authorities first ac-cepted the notion of contagion. The story to follow illustrates thatthere were two divergent traditions of evidence, argument, and ac-tion governing the behaviors of these two different authoritygroups. How a physician could believe that the disease of an indi-vidual patient was contagious depended upon acceptance of a verydifferent view of plague experience from that guiding health of-ficers. Reflecting partsof the society's overall commitment to con-tagion principles during plague, the Milanese evidence suggeststhat the variant experiential data supporting these separate tradi-tions in contagion theory and practicepermitted general governingauthorities, in this case the duke of Milan, to vacillate between thephysicians' and the health officials' differing solutions to the man-agement of plague.

    Public Health Practices in Milan, 1350-1468Very little is known about the Black Death and the second plagueepidemic in Milan other than the fact that Milan, as an inland city,may have escaped infection until 1360. In 1374, however, the thirdwave of plague to hit urban Italians, Duke Bernabo Visconti pro-

    mulgated a version of the earliest quarantinelaws ever made, con-centrating on the restriction of movement from plague-strickenterritories into the ducato, he lands controlled by the duke of Mi-lan.3In I399-1400, his successor, Giangaleazzo Visconti, an excep-tionally able military leader and administrator, took such an activepersonal interest in plague control that records of procedures at theparishlevel can still be gleaned from his dispatchesand general cor-respondence. Probably not all of the epidemic controls and strat-egies for crisis management were novel to Giangaleazzo's admin-istration, but the core program evident sixty years later had

    3For the legislation see the Chronicon Regiense, 82; Corradi, 1:224-25; and Grmek,40-42.

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    certainly been established by this early date.4The duke intervenedin three specific ways. First, he demanded notification concerningall illnesses and deaths in the city, in the process setting up a mech-anism for regulating part of the practice of medicine in the city.5All illnesses were to be reported to the appropriate parishelder (an-ziano), either by the physician caring for the patient or by the headof household. The parishelder then notified either the officialidellebolletteor the duke's hand-picked commissar. The specific notifi-cation proceduresand the regularizationof this process were firmlyestablished by 1438 and were repeatedpracticallyverbatim duringthe tumultuous years of the Ambrosian Republic (1447-1450), theoligarchy formed after the death of Filippo Maria Visconti left nolegitimate heir. Political revolutions did not change this reportingprocess, which had been extended to normal as well as to epidemicyears during this half-century.Second, Giangaleazzointervened in the creationof an official po-sition, the commissario,overseeing all health regulations in theduchy as well as in the city of Milan. Scattered evidence fromsmaller Lombard cities during the first half of the fifteenth centurysuggests that the scheme of confirming the causes of both illnessesand deaths was extended throughout Milanese territory and that incrisis years a second tier of administratorspersonally responsible tothe duke sifted through all the information in order to coordinatedefenses throughout the territory. Thus the commissioner's officeprobably originated as a temporary solution to epidemics. Com-missioners were appointed in 1419 and 1424, and again during thebrief-lived Ambrosian Republic.Third, Giangaleazzo interfered in the use of hospitals and hos-pital resources, regulating how the commune would conscriptemergency personnel, possessions, housing, and sustenance forthose touched by plague. Ecclesiastics could be fined for buryinganyone whose family was not provided a burial license, the endproduct of the reporting and registration process developed in de-tail. 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, 14-17, 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; andBelloni.

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    severely limited during the crisis. Other houses or hospital prop-erties controlled by the Church could be assigned careof those re-covering from plague (not everyone who got plague died), or eventhe overflow patient population normally absorbed by the existinghospitals. Thus, at least from the time of Giangaleazzo Visconti,carefor the poor and carefor the plague-stricken were overlappingconcerns of the state, a state that asserted its right to set aside theclaims of privateindividuals and religious institutions wherever theneed to combat plague demanded.6These premises of public health control still operated a half-century later, but little real change had occurred. Giuliana Albini'sthorough study of the topic teasesout the details of plague and gen-eral sanitary legislation and practices, finding the only significantchange administrators'gradualacceptanceof in-house confinementduring plague times. Giangaleazzo'sapproachto plague control in-volved strict segregation of healthy from infected, placing a heavyburden on officials to remove from the city all individuals diag-nosed with plague, and to create houses of recovery that would im-pede the re-introduction of plague. Firmly believing plague wasspread by contact, Giangaleazzo was aware that both those livingin the house with the ill person and those who had come into con-tact with the household were tainted and should be separatedfromthe general community. Early in the century, administrators des-peratelytried to keep up with the construction of temporary shacksor cabins away from the city or the assignation of monastic or hos-pital properties for quartering these people, in addition to effortsin providing for those who might perish without state charity. Al-bini concludes that by mid-century the necessity of quarantiningcontacts in their own houses became both a political and an eco-nomic necessity, even though health officials, applying strict con-tagionist models, could argue that the procedure would exacerbateplague in the city. Plague would surely spread to all members ofthe household, multiplying the sources for new cases if quarantinewas not both lengthy and rigidly enforced.

    6Albini, 63-78, esp. 68. I argued that plague and poverty were firmly associatedduringthe earlyfifteenthcentury,but for analtogetherdifferentreason:mortalityex-perienceduring plagues fueled this administrativeconclusion;see Carmichael, I986.Albini'sbook, unavailable o me when Iwrote my study of Florentinedeaths,containsa richdiscussionof the late medieval notions of poverty as well as how administratorslinked theirperceptionsto specific plague controls.

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    Plague entered Milan in 1449, despite the Ambrosian Republic'sbest efforts to follow every detail of traditionalsanitaryprocedure,gaining the full cooperation of Milan's College of Medicine as wellasbenefiting from the contemporary reform of hospitals so that thefull resourcesof these wealthy institutions could be directedto con-trolling the problems of poverty and famine. Ironically, the veryvilla Giangaleazzohad used as a refuge from plague in 1400 was ap-propriated first as a shelter for the mendicant, desperate poor col-lected from the streets of Milan, and then for the city's first make-shift lazzaretto(pest house).7 In 1450, Francesco Sforza, a brilliantmercenarysoldier equally successful lateras an administrator, tookpossession of Milan from the Ambrosian Republic. His victory wasaided in part by marriage to Filippo Maria's daughter, BiancaMaria, and in part by the coexistence of this devastating plague inthe city, eclipsing the resources of the republic. Sforza made polit-ical capital of the population's weariness with war, plague, andfamine, but he did very little to change reporting and isolation prac-tices in the middle of the epidemic. He did receive notification per-sonally, probably daily, of the deaths and new suspicious illnessesin the city, though few of these bulletins now survive. By 1452, asplague was receding, the bulletins that had so long been requiredof parish elders, physicians, surgeons, barbers, and herbalists, re-porting deaths in the city by date, age, sex, cause, parish, and cer-tifier of cause-of-death, were written into the first survivingNecrologior 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 ofSforza rule in Milan. First was death reporting, where by decree,heads of household were to report in writing both illnesses anddeaths to their parish'selder. If an individual was under the care ofa physician belonging to the prestigious College of Medicine (allwere university-trained physicians and surgeons), the physiciancould by-pass this step on behalf of the family. Barbershad to gainthe permission of a collegiate physician before attending any pa-tient; all surgeons, herbalists, and barbershad to call in a collegiatephysician 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. Fordetails 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)orby an elder's testimony. The elders were obliged to submit a dailyreportof these illnesses and deaths to the officials "deputized for theconservation of health" or the "health commissioners of the city ofMilan." The older officialidellebollette,had by mid-century split itsduties, one (the older, original function) governing the registrationof all visitors to the city, lodged in private houses or in inns; andone governing the other aspects of health surveillance dating fromthe time of Giangaleazzo. In other cities of the duchy and in someneighboring territories, the sanitaryoffice was still handled by localofficiali delle bollette, but by mid-century, Milan's officers werecalled "officali deputatia la conservatione de la sanita"or "officialessupersanitate servandain urbe Mediolani" or simply "commissariisanitatis."XBecause Milan had a population of around 60,000 by the I450s,it was large enough that the position of commissar served both localfunctions and, to some extent, general health controls throughoutthe duchy. Here the overlapping jurisdictions created some slightmanagement problems, such that the duke could receive detailsabout plague in Milan, or plague in Pavia, Piacenza, Crema, or Cre-mona, for example, either from the deputies of public health, orfrom a more general governing agency, such as the Secret Counselto the duke (Consigliosecreto).Since it was unclear throughout thesecond half of the fifteenth century where crucial information aboutplague should first be directed, correspondence to the duke couldcome from the Secret Counsel, usually concerned with affairs ofstate such as peace treaties and war; from the duke's personal ser-vants such as his secretary, general informants, and messengers;from the health deputies; from the commissioner; from other cities'boardsof health or officiali delle bollette; or from his personal phy-sicians. Forexample, there were at least three possible copies of anydeath report in normal years: one from the parish, one permanentrecord in the Necrologi, and one in a daily summary letter to theduke. During the year I shall discuss below, death reportswere car-ried to the duke from the deputies, the health commissioner, theSecretCounsel, 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 wasrare,however, that the duke would have been informed about cityevents directly by a physician. For the most part, the physiciansseem to be peripheralto the main process of public health control,that is, they were not the decision-makers. The extent to which in-put from particularphysicians may have been crucialto changes inpublic health practicesis important, and a question to which I shallreturn shortly.Some changes in public healthpracticesaccompanied Sforza rulein Milan, however much they built on older traditions. FrancescoSforza'srelationshipto the process of plague andgeneralhealth sur-veillance, insisting that he be fully informed of the minutiae ofhealth in the city at all times, recalled something of the personalcontrol exercisedby GiangaleazzoVisconti. FrancescoSforza other-wise appearsto have been concerned most with the reform of hos-pitals and the aggregation of their extensive properties in the cre-ation of a central receiving and acute care hospital, the famousCa'Grande or Ospedale Maggiore. Sforza dedicated the groundsand inauguratedthe building of the hospital in 1456.9 He seems tohave left other details of health control to his secretary, Cicco Si-monetta, and to his personal physicians, especially Benedetto daNorcia.Francesco Sforza died in 1466, leaving the government of Milanin the hands of his wife, Bianca MariaVisconti, andGaleazzoMariaSforza, his oldest son. Mother and son shared controls for just acouple of years, her voice usually the stronger, until three simul-taneous processes effectively placed young Galeazzo Maria in full,uncompromising control. First, he completed negotiations for apolitically superb marriageto Bona of Savoy, bringing Genoa intoMilanese control. Though only in her early forties, Bianca Mariafailed to keep ahead of chronic illness. And finally, plague reachedMilan. In 1467, plague, common to all the cities and territoriesofsouthern Italy, crossed the river boundariespatrolled by the duke'smen. In 1468, it reappearedin the city. Because Galeazzo Mariaplanned his wedding celebrations to include a triumphant tour ofhis domain, beginning in Genoa and ending in Milan, his personalinvolvement in plague surveillance and control was much keener

    9Spinelli.

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    than his father's ever had been. oAll levels of Milanese administra-tion ultimately had to contend with his understanding of the causesof plague, his preferences for exercising controls, and ultimately,his anger at their failures. But there was enough of a political vac-uum created after the death ofFrancesco Sforzathat the young dukehad to craft his own understandingof the role physicians and healthofficers should play. Galeazzo Maria Sforza's correspondence withofficials betrays his attempt to "micromanage" the epidemic froma safe distance, inserting his orders and ideas into the process ofplague control almost as much as did his great-great-grandfather,GiangaleazzoVisconti. Both officials and advisors were quick to in-form the duke what his opinions about plague control should be.Galeazzo Maria's own anxieties about the wedding plans as well ashis political need to assume unchallenged control of Milan and theduchy may account for his unprecedentedinvolvement in the med-ical and public health details of an unfolding epidemic.

    Medical Traditions in Milan, 1350-1468Milanese physicians had an ambivalent relationship to the use of"contagion" in medical theory, even though the College of Phy-sicians had since 1396made plague-related exceptions to its rule thatcollegians should attend the funerals of others in the college. Ifa col-league died with a "contagious or pestilential malady," his fellowsdid not have to go to the interment or carry the bier.I Given thisunwillingness to touch plague, the physicians as a group may havebeen reluctantto perform any kind of postmortem verification thata person died of plague. College physicians did perform autopsies,presumablyin the study of human anatomy, for the statutes of boththe college and the city of Milan in 1396 allude to the yearly pro-vision of a corpse and a place for dissection. 12The physicians didnot, however, express unqualified support for a contagion modelof plague, nor did they make recommendations similar to thosepublic 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 typ-ical location for dissection. One of the anatomists, Iacopo da Firenze, served as the sur-geon to the Sanita in the 1450s plague. Toward the end of the century autopsies wereperformed with such regularity at the Ospedale Maggiore that they had to be regulatedby the directors. See Spinelli, 112.

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    lodged in the ways in which a diagnosis was made when a physiciantrained in Galenic medical theory was confronted with an ambig-uous clinical history or ambivalent "signs" on the body of the illperson.The following, tortured description of what seems to me astraightforward case of plague will help to illustrate the clinicalproblem with contagion theory in the fifteenth century. Here theprincipal physician to the Sanita, Giovanni Catelano, reported asuspicious case on 20 May 1468:Gotardo e'Magi,thirty-five earsold, fellill onTuesday bout hehourofmass,with anapostemen his eftgroin,aboutwhichcase amdoubtfulandperplexed.There s thatwhichaccusesandthatwhichexcuses.Firstthe short imeperiodaccuses.But his horsebackiding xcusesbecause ewas unaccustomedo it and becauseanaposteme an arise hisway. Hehas a sonwho Mondaywasbittenby a rabiddog, . . . whichcausedhefather oseizeand o weaken onsiderably,ither ncompassionorthesonorpossiblyby contagion f rabies contagioneabiey],orrabiess amongthecontagiousdiseases]. uesday veninghe returned ome[afterkillingandburninghedog]withthisweakness, ausea ndapostemewhichhavepersisteduntil now (i.e., for threedays). But I could be persuaded hat theapostememightbe causedby the rabiesvenom morethanby pestilentialfever.Forrabiessof a coldanddry,melancholicumor,and tsrespectivevenom more detrimentalo thespleen hanto theheart. Here ollowsadescription f whatkindof materialCatelanoandotherdoctorsthinkmightbe inside hisswelling.]The urine s laudable,but he hasbecomealienatedstuporous]ver thepastnight,andhasbeenvomitingbitterac-ids. Since hisappearso alleviate issuffering shallvisit himandthinkover thecase.'3

    Aside from the fact that the physician has chosen to take the pa-tient's story seriously, this account shows how Catelano was simul-taneously wrestling with the different causative physiological pro-cesses that could explain an acute bubonic swelling and with thenosological dimensions of contagious and noncontagious diseases.In other words, Catelano's interest in whether or not rabies be-longed among diseases classified as "contagious" may have beenlinked to here-unrehearsed debates about whether plague shouldalso be categorized as contagious. But deciding what caused Go-tardo's aposteme involved a different sort of evaluation, one re-viewing all the possible ways in which apostemes could appear. Inthis 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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    apostemes. 6 What made the former contagious was the poisonthey contained, an important point to which I shall shortly return.On the possibility ofnoncontagious apostemes, much the same dis-tinctions are made by Milanese diagnosticians as in Montpellier, soit is not surprising to find detailed differentiation from plague ofapostemataor swellings that were believed to have originatedother-wise. Three examples from 1468:[une 6, a thirty-year-old man], reseen after death: found to have an apos-teme behind the left ear, but already mature, emitting pus mixed withblood, which is believed to have come by way of a crisis of the illness whichfinally took him after twenty-two days; not worrisome, according to Cat-elano.

    Bertola de' Rigoni, twenty-two years, . . was seen while alive andfound to have swelling or aposteme in his left side, toward the front, thatwas 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 certainlividness and a little excoriation, and the urine was good and abundant, butunexpectedly he died after twelve hours. I returned to see the body. An-other large swelling over the groin was found in addition to the other. Hedied Saturday, that is, yesterday [une 6] at twenty-two hours. By thejudg-ment of Catelano.

    [August 5] Emanuel, servant of lord Ubleto da Fisco, twenty-five-years-old [died] from a bubo [dragonzello]in the right groin, because of anulceration of the propoltius[?] due to an ill-considered application of con-strictive medicines. The putrid matter turned back inward to the interiorand this caused a continuous, proportional tertian fever, not suspicious inthejudgment of Maestro Stefano da Trivulio and Dionysio de' Ceruti, sur-geon. '7Earlier reference to rabies is rather more difficult for us to un-derstand because we live a post-Pasteurian world that recognizesrabies virus has an incubation period of at least two to eight weeks.i6But Chase has us understand"accidents"by the term "symptoms," which hashad a long andvaried medicalhistoryandmay misleadmany readers.Symptoms cur-rentlyareconsidered o be thesubjectiveexpressionof illnessby thepatient,specificallywhatcausessuffering o anindividual. SeeFoucault,90-94 on theearlymodern medical

    usage of "symptom"; and King, 73-89, for what "symptom" means today.'7MS, i, passim, by date.The lastexample,however, is foundin Sforzesco,Carteg-gio interno,883, 5 August 1468:"Emanuelfamulus domini Ubleti de Fliso, annorumxxv, [decessit]adragonzello n inguinedextropropterulcerationepropoltiiex indebitaapplicationemedicinarumconstrictivarum.Reversaest materiaputredaad intra. Et siccausa est febris tertianacontinuaproportionalis,sine suspectu, iudicio M.ri Stephanide Trivulio et Dionysii de Cerutis, cirugici." It is quite possible that this man had aplague bubo lanced, treatedwith poultices and constricting unguents. Surviving thefirst disease, he succumbed to secondaryinfection of the lesion.

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    But according to medieval tradition, rabies was classified among ashort list of "contagious" diseases, diseases that could be acquiredonly through contact with someone (possibly an animal). The listof contagions was short: phthisis, ophthalmia, anthrax, epilepsy,"sacred fire" (either ergotism or erysipelas, or both), scabies, ra-bies, and leprosy. 8 What made a disease categorizable as conta-gious related more to notions of the disease's transmission than tothe specificity of the individual disease phenomena. For example,measles and smallpox, indeed most of the "exanthems" or rash-bearing diseases, reflected signs of inward processes registered onthe body surface. The modern concepts of disease specificity, forexample, that the measles rash is identical in each and every personwho suffers it, was first most clearly stated by Thomas Sydenhamin the I68os. As early as the I 540s, Girolamo Fracastorosettled onthe idea of a "precisely similar corruption," which approximatesthe idea of specificity. '9Before this time, Galenic emphasis on thedeterminative influence of an individual's unique humoral compo-sition governed most clinical thinking. Instead, medieval and Re-naissancecontagious diseases fit better into explanations of poison-ing. It is in the treatises on poisons, in fact, that rabies is usuallydiscussed, and poisons were a medical topic of longstanding inter-est to the Visconti lords of Milan.20Thus it is interesting that onesubgroup of physicians, not under the control of the College ofMedicine, did have a strong tradition with regardto the idea of con-tagion in plague. These were the ducal physicians, who from thetime of Bernabo Visconti presented plague treatises that are fre-quently seen as the earliest sustained commitment to a contagionprinciple. Cardone de' Spanzoti was the first of these, presentinghis De preservatione pestilencia o the Visconti in 1360, in which headvises the usual flight from turbid, humid airs, rectification of the

    '8Grnek, 25ff., provides a different list of the traditional contagions than does Nut-ton, 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 inAristotle, Galen, and popular tradition. Guainero wrote that rabies can manifest thisquickly after infection; see Thorndike, 4: 226. Temkin provides yet another list of thediseases commllonly assumed to be contagious during this period.I'Winslow.

    2Thorndike, 3: 525-45. Thorndike, 4: 217, explicitly links the literature of conta-gions and the literature of poisons.

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    airby burning woods and herbs if flight is not possible, all becausethe "morbo pestilenziale e contagioso."21The most famous of all fourteenth-century plague tractates,surelyone of the two most often reprintedlater, was Pietro Curialtida Tossignano's Consiliumpropesteevitanda,dedicated to Giangale-azzo Visconti in I398. Tossignano has the most definite notionsabout contagion theory of any physician before the sixteenth cen-tury.22He argues that "it is safer to move to a region where therehas never been an epidemic than where pestilence has reigned evensix months back, since the 'reliquiae' will remain and, acting likea ferment, will infect those who come into the locality." And hespeaks both of contagious houses and the poisonous content ofapostemes. Tossignano is justly famous because he was willing toaddress both the public health dimensions of plague controls andthe clinical treatment of individual plague cases.This was not true of collegiate physicians. For example, AntonioGuainero became one of the most prominent of Milanese physi-cians during the early fifteenth century, dedicating his treatise onplague and poisons to Filippo Maria Visconti. Guainero taught atPavia for a major portion of his long career in Milan (I412-ca.1448), and counted two of the Visconti court physicians among hispreceptors.23Delivering his treatise in both longer and abridgedforms sometime before 1440, Guainero was possibly trying to se-cure Visconti patronage. Guainero was predominantly a clinicianand clinical teacher, and his plague treatise, while claiming to bedrawn from standard, long-known medieval sources, is at timesquite different from comparable literatureof the day. He prefacesthe work by acknowledging that "some say plague is a contagiousdisease" transmitted in touching, even though much of the discus-sion, following tradition, maintains that plague is generatedfirstbycorruption of the air.24Guainero, however, does not venture a dis-

    'Panebianco. See also Belloni, 61 3. Two other physicians to this generation of Vis-conti wrote plague treatises: Giovanni Dondi and Maino de Maineri. The latter wasprobably the son of Visconti physician, Pietro Maineri. See Castiglioni; and Palmer andZitelli.

    -2See Singer, 187-89; and Mazzini.:3Thorndike, 4: 2 5-3 I, 674-77. Luchino Bellocchio and Giovanni Francesco Balbiwere personal physicians of Filippo Maria Visconti, as were Petrus de Monte Aranoand Stephanus de Burgo, to whom Guainero refers on other occasions. See also Lemay.-4Guainero, f. i68v: "Dicitur et aliter pestis contagium a contangendo quia quemtetigerit popuit vel quod ex unius contactu ad alios se facilinie transfert. Et ideo Isidorustertio ethimnologiarurn pestilentia inquit est contagiumnquoddumnunumncomnprehendit

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    CONTAGION THEORY AND CONTAGION PRACTICE 227cussion of public health measures for the control of plague, defer-ring the matter to appropriatecommunal authorities.25An unwill-ingness to dictatepublic policy seems to differentiatethe scholastic,university-trained collegiate physicians from ducal physicians notallowed such a refuge.Strikingly different are the policy recommendations made byphysicians who advised the Visconti and Sforza dukes aboutplague. The last of these, in the period before 1468, was BenedettoReguardati da Norcia, who became the personal physician toFrancesco Sforza when the latter was still a military condottiere.With Sforza's rise to power, Reguardati was called upon to advisethe duke about plague controls, which Sforza passed along to theSecret Counsel. 26 In 145 I, Benedetto was concerned with assessingthe health conditions of the city, specifically the ambient air, buthe also proposed an interesting solution to the trade problemsplague controls presented. He suggested the equivalent of a neutralzone, or portion of road between Milan and Pavia, where goodsmight be safely exchanged: a solution to quarantineproblems withcommercial goods that would become common a century later.27A member of the Secret Counsel in 1464, Benedetto may have hadfurtherdirect experience with managing plague. But most impor-tant to the events of 1468, letters from Reguardatito Duke GaleazzoMaria Sforza in 1467 reveal his significant intermediary role. On 8May, 1467, he reassured the duke that all the identified cases ofplague had been imported, that is, they resulted from contact withplague outside Milan. He urged the duke to protect himself byavoiding all contact and conversation with anyone who came fromplaces where plague reigned and to interpose human barriers whenhe had to deal with anyone who could have had contact withplague. 28 Ten days later, in a letter concerned with many diplomaticad alios celerime transit." Interestingly, Guainero is aware of Isidore's discussion ofcontagion in the Etymologies (7th century A.D.); Nutton, 20-21, contends that Re-naissance authors overlooked Isidore.

    2'Guainero, f. 70ov:"Et illo modo per viam contagii plures civitates ac ville fueruntinfecte. Qua de re reipublice gubernatores conversationem locabitantium infecta suisdebent 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 chene 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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    RENAISSANCE QUARTERLYandbusiness matters, Benedetto remarked that he knew Milan hadbeen relatively plague-free, until he got "the list of the officials ofthe Sanitaat 22 hours today." It is interesting, of course, to spec-ulate that individuals among the physicians to the dukes, or evenjust this one, intercepted the lists of the deaths and illnesses of thecity, filtering the information that went on to the duke. Benedettoalso mentions his devotion to the contagion model: "[these cases]do not surpriseus or cause anxiety, because we clearly see them tooccur through contagion." Thus the city could be purified easily.29Reguardati wrote very traditional health advice and conferredwith colleagues at Pavia on medical matters. He subscribed to theastrological medicine especially favored at the university at Pavia,all of which suggests that his connections with the health magis-tratesstimulated his open subscription to, even innovation regard-ing, contagion practices (not theory).30 Until young GaleazzoMaria came to power at age twenty-four, the dukes of Milan mayhave been comfortable with physician intermediaries. GaleazzoMaria was delivered and raised by Maestro Benedetto, who de-scribedhimself as "more nurse than physician" to the heir, and theduke was clearly torn by Benedetto's supplications to return toTuscany, a long-cherished desire, and his own mother's demandthat the dearly beloved physician remain in her service.31 Onlyupon Bianca Maria's death in October, 1468, could Benedettoleave, severing one sure link between university physicians, theduke, and health magistrates.

    Negotiating the Diagnosis of PlagueHowever sophisticated the observations of plague infection anddeath from plague revealed in many of the physicians' records, theabsence of a theoretical defense of the transmission of disease by'9Sforzesco, CartceVio nterno, 880, 18May 1467: "Per lo dio gratia doi di passati inMilano non e suto ne morto ne Infecto alcuno de peste. mal al presente ad hore vintidoyme venuta la lista del officiale della sanita che nel borgo de porta Comasina che in unostallo di piu fameghe ne sonno infirmate de pestilentia dove nelli di passati n'erano mortitre. Questo non ce da maraveglia ne grande affanno perche vedemo manifestamienteessere 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 appearin Sforzesco, Cartcggiointcnro,883, 15 February 146x (with a second letter this day fromthe duchess to Cicco Simonetta to urge the duke further), and in other letters reprintedin Deffenu.

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    contagion hindered direct discussion of the problem of contagionwith public health officials. While those trying to anticipate thespreadof an epidemic understood the problem of contagion theoryas one linked to Hippocratic notions about how an infection couldbe transmitted from one person to another, physicians focused onthe problem at the level of distinguishing which humans were infact infected with the plague poison or putrefaction. Thus physi-cians regardedthe means of conveying the disease from one personto another largely irrelevant to pressing diagnostic and therapeuticissues. Contagion was not the starting point for medical thinkingunless one began by accepting that diseases, like poisons, were in-dividual entities entering human bodies. Thus lvhatwas transmittedwas ultimately to become more important to physicians' theoreticalunderstandingof contagion than how disease could be transmitted,for Galenic and Hippocratic theory seemed to account adequatelyfor both successes and failures to transmit disease from infected tohealthy individuals.Frequently, plague had to be the conclusion even though no clin-ical evidence could affirm the diagnosis, thus challenging and wid-ening the physicians'basis for making adiagnosis. Clinically, phys-iologically, plague was known by two very different sets ofdescriptive evidence. Most of all, it was a profound imbalance ofthe humors that accelerated putrefaction around the most vital ofall organs, the heart. In order to apprehendthat process externally,physicians had to rely on outward "signs" and discrete changes inthe patient's urine. On the other hand, plague was suspected if aperson progressed from health to death in less than five days, or ifhe or she died in a place where other plague deaths had occurred.Here classical theory had no framework for translating epidemio-logical information into clinical sign or symptom. An epidemic dis-ease, since the time of Hippocrates, was an epidemic because it hada cause common to the entire population affected, such as corrup-tion of the ambient air, or through contaminated food, or throughastrological changes impinging upon the terrestrial world. The in-tersection between clinical information and epidemiological infor-mation was as difficult then as it often is for laymen today.32

    32Many nonspecialists today trying to understand infectious diseases accept stronglydeterministic versions of the germ theory of disease and reject statistical models of cau-sation. In fact, many things we consider to be discrete diseases fail to satisfy Koch'spostulates for proving the causal relationship. See Evans.

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    "Plague" in practical, emergency conditions could encompassfar more than the texts allowed. But even had the narrower, clinicaldiagnosis carriedgreater weight, positive plague "signs" included:"blackmeasles," "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 fe-ver), "malignant pustules," anthrax-any one of which could oc-cur alone or in combination with a bubone, landula, dragonzello,orother aposteme. In such circumstances, it was difficult to viewplague as a discrete disease, unique in its clinical appearance.

    Because the doctors were diagnosing more with an eye to pro-cess, to the pathophysiology of plague rather than the essence ofplague as a thing foreign to a body, passable from one to another,their best efforts to comply with the health officials tended to un-dermine contagionist efforts. "Today we have two cases," the dep-uties wrote, "through which, according to thejudgments includedbelow, we are doubtful and perplexed." With that, May 2I, theyrepeated the language of Catelano the day before (the rabies caseabove): "And for clarification we diligently consulted the physi-cians deputized to oversee this, who through that which they havebeen able to understand and know by the script of this judgment,neither absolve these cases entirely nor condemn them."33One ofthe cases involved the female servant of a doctor-this time theprestigious collegian Maestro Francesco de' Medici da Seregnio.She was twenty-five-years-old and had anaposteme in the right ax-illa. The case was arguablebecause she had several times before haddifficulty (malo)in that spot, the part could have remained debil-itated and "could have easily generated that aposteme, not, how-ever, pestiferous." The case report does admit that whatever thecause of the swelling, the woman's urine was "confused," possiblymeaning cloudy, and she was in pain "from her head all the wayto her feet on this same side." On the other hand, surgeon Dionysioequivocated, the fever was not intense. Perhaps Dionysio wasswayed by the logic of the great physician, whose home would besealedif he could not persuadethe young surgeon the case was real-ly more complex, but the Sanitaalso had to believe the story in or-der 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 May1454; 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 es-char,would have been a clear case of aplague pustule, but the lesionappearedon the left breast-not typical of plague. Thus the dep-uties decided to let the physicians wait for surersigns. If the womenworsened, it would be plague. If not, not.35Believing in contagion as the magistrates did, very few deathsoccurring in a confirmed, infected house, or at the lazaretto, or inthe cabins, were ever considered anything but plague. Singly, newcases awaited the surest medical "signs." Rapidsuccession of deathsin a household helped to speed diagnosis and action: "Today [23May 1468] we do not have any new case except a woman namedCatharina,the wife of Tomaso da Pergamo, who died recently un-der suspicion; she became ill yesterday and tonight will be taken tothe deputized place."36By the same measure, recoveries begged adiagnosis of non-plague. Arguing, as usual, that they were exer-cising extreme caution, the deputies wrote the duke May 27 thatthey exported everyone in Giovanni Bono's house to SanGregorio,despite the fact that the house was largeenough thatthey could havebeen separatedfrom neighbors effectively. But "we were not evencertain that the case was truly suspect, there being at the same timein this house another sick person who recovered."37 Meanwhile,every time there was a reprieve in the death count or the pace ofnew cases, the deputies were willing to take advantage of the phy-sicians' ambiguity in diagnosis: "Things are going well, throughGod's grace, and we hope they continue to improve. These phy-sicians are beginning to change their sentence andjudgment, andnow hold the firm opinion that no excessive news will follow, be-cause now some tertian fevers have begun to appearand these donot convert into suspicious illness, from which we take muchhope."38 Fuller discussion of the events of 1468 help to illustrate

    short-lived Studium of Milan; see la Cava. Dionysio appears in the Necrologi recordsin the late 1460s, but is both a foreigner and a surgeon, never joining the College. Hedied in 1504, at the age of 80; see Motta, 256.3sMS, 2, no. 44: "Pur per piu secureza havemo deliberato che questa sera sia revistaet secundo sara il caso si guovernaremlo. Domani per il nleglioramnento, or per pegio-ramento che fara la fantescha de dicto M.o Francescho se intendera chiaramente si sarasospecto o nonl."

    36Ibid., no. 46.37Ibid., no. 50.38Ibid. (27 May).

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    how physicians and health magistrates were called to defend theirseparate traditions of contagion theory and contagion practice.Galeazzo Maria Sforzaand the Path of Plague

    In 1468, physicians, health officials, legislators, the duke, and hispersonal staff were all involved in the process of identifying andoutlining what conditions presenteda threat to the state. Effectivelythe Milanese public authorities delimited the parametersof conta-gion practices before physicians could explore and articulate theways in which contagion theory posed serious challenges toHippocratic/Galenic physiology, for the physicians were mostconcerned with understanding how contagious disease could un-dermine body defenses. Then as now, clinical data did not neatlyaddressepidemiological questions, though the debate was not seenin these terms. Most of the numericaldataabout this epidemic mustbe gleaned from letters, because no bound registers of the Sanita'sNecrologi now survive. 39But the Sforza dukes retained so muchof their personal correspondence, among which many notices ofdeath and illness reports during 1468, from both the deputies ofhealth andthe SecretCounsel, that we canreconstructhow the pro-cess of diagnosing plague was negotiated and argued, the practicebehind an emerging theory of contagion.It was probably inevitable that plague would reachMilan, for allthe major cities of Italy from Rome northward were stricken be-tween 1464 and 1467.40 The deputies of health repeatedly warnedthe duke thatadditionalfunds would be necessaryin posting guardsat the gates, rivers, and major thoroughfares flanking the duchy.Early in March 1468, a few plague cases were identified inside Mi-lan, most of them associated with one large household.41 After afew satellite cases appeared in late March, there was a period ofcalm: "for twelve days now, by the grace of God, no case of plaguehas 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 thehealth officials worked, probably accounting for the numerous lacunae in the latefifteenth-century series of registers. The scribe notes this in the 1503 register, and thetext 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 toplague cases among one large household, the Lampugnani, e.g., MS, 2, no. 2, 25 March1468.

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    duke on April 6.42 But later the same day the counsel heard rumorsthat a thirteen-year-old boy died "not without suspicion ofplague," and they immediately contacted the deputies for confir-mation. The deputies of health in turn dispatched their physician,collegiate physician Giovanni Catelano, who had extensive expe-rience diagnosing plague during the 1450-52 epidemic. Catelanoreported that he was in agreement with another college physician,Maestro Marco da Roma, that the signs surrounding this deathwarrantedcaution. Although the boy's urinegave no clearevidenceof plague, andhe died afteraneleven-day illness, the inguinal swell-ing was a new finding when they inspected the corpse. Catelanothought that perhaps the boy had arisen too soon after his febrileillness and this was a recurrenceresulting in an aposteme, exacer-bated further by rainy weather. Nonetheless, Catelano admittedthat the course of illness could be attributed to a body "disposedto contagion."43Marco's report (via the deputies' letter) noted theswelling in the right groin, a continuous fever for eleven days, andblood-tinged urine that could not rule out the fever as pestiferous.The Secret Counsel decided to impose cautions despite the physi-cians'judgments, giving the household the option of remaining un-der house arrestor going to their villa. They were to stay separatedand not have any dealings with others.44 Officially this was thusjudged aplague death even though the medical evidence was equiv-ocal. The duke's magistrates superficially accepted the medicaljudgments about early plague cases but separately concluded thatplague controls should be applied whether or not these stricken in-dividuals actually died of plague. In taking the doctors' testimonywith a grain of administrative salt, the deputies and Secret Counselwere also assuringthe duke that theirview of the situation was saferfor the city than the physicians' more tedious analyses.Ten days went by without another worrisome death, but the of-ficials were clearly unsettled. The next official plague death on I6April, an eighteen-year-old girl who had been ill for four days, wasattributed to her living next to the house of the first cases of earlyMarch. The physicians almost certainly agreed that she had plague,because they reported a bubo in the left groin and "succeedingevents" (accidentibus).n this caseno other potentially confusing de-

    42Sforzesco, Carteggio interno, 883, by date.43MS, 2, no. 3, 6 April 1468.44MS, I, no. I36.

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    RENAISSANCE QUARTERLYtail was offered. We can infer from surviving correspondence thatthe duke was informed when this girl first fell ill, for HectorMarchese,45 he health commissioner himself, wrote to the duke onApril 17that he had gone to visit another member of this householdbecause the duke so ordered him. The ill man that he saw was thenexiled from the city, to go to his villa or to one of the designatedplague houses, along with three siblings. Hector assured the dukethat if this man disobeyed in any way he would be punished "in amanner thatwould provide anexample to others."46Another deathon April 23 called forth plague controls because an immediateneighbor of this six-year-old girl had died a few days before. As inanearliercase, she showed no convincing signs of plague infection,but the girl had anenlargedinguinal gland. Though Catelano foundthe urine "good," provisions were made. Catelano was not willingtojudge this case plague on the basis of a "glandula"alone, becauseurinalysis was a crucial factor for him, but as the physician ap-pointed to the Sanita he acquiescedto the demand for precautions.47By late April the Secret Counsel and the deputies of health hadtranslatedtheir worries into a set of provisions, bracing themselvesfor massive evacuation of the city even as they offered up an ex-planation to the duke of the origin of the illnesses and deaths iden-tified. One neighborhood around the Cinque Vie (Five Points orFive Streets)48was seen to account for almost every new case ofconfirmed plague. The original cases in early March had occurredin the parishof St. Pietro della Vigna (see map), and all the satellitecasesof March and early April occurred in this or a contiguous par-ish. The first mention of Five Points occurs, however, in a letterof 27 April from the Secret Counsel, noting a new case in a mannamed Maestro Legutero. At this point two different shelters in thecountryside were set up to receive healthy suspects, and San Gre-gorio was designated to receive the ill.49All the guards on passes,

    45Mostpropernames in the Sforza archivesappear n Latin,and I have translatedthem to Italian. Hector Marchese is the exception:becausehe always signs his name"Hector," even when writing in Italian,I have preservedthis form.46MS, , no. . This story is appended to a normal death report and begins, "o vistoquanto me scrivi la excellentia Vostra circhail fato di Ambrosio, nepote di SymoneMantegatio. .. ," thus alludingto a letter from the duke to Hector.47MS, I, no. 292.48Anineteenth-centuryphotographof the areais provided by Branduani,72-73.49MS, 2, no. 6, 27 April. One of the purposes of this letter seems to be shifting theblame for plagueaway from administrative rrorto the argumentthatplaguewas ev-erywhere n Italy,especially n theprincipalcitieswith which Milantraded.SeeAlbini,101.

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    Santa Mariaal CircoloMAP OF MILAN WITH FIFTEENTH-CENTURY PARISHES

    roads, and rivers were put on full alert, much like closing the barndoor after the horse has escapedThe surviving letters from the end of April and first week of Mayreflect only the tip of the iceberg of a growing panic in the city.Conducting business normally became less possible as the circle ofcontacts of plague cases and plague houses widened. For example,one of the members of the Secret Counsel failed to show up forwork. The duke, somehow informed of his absence, immediatelydemandedthathis salarybe withheld. On 2 May the deputies wroteto explain that the man's daughter had entered the house of a priestwho subsequently died of plague; thus the councilor had voluntar-ily absented himself from the city for a few days.5sWithin a week'stime the city would empty of its better citizens, including the duke'smother and her extensive entourage, bound for her dower city ofCremona.5s Galeazzo Maria's wedding was set for midsummer,and wealthy Milanese would normally have housed dignitaries at-tending the wedding, so the exodus was amatter of utmost concern

    SOMS, 2, no. 9.S'For a good discussion of flight from cities during plagues, see Mazzi.

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    RENAISSANCE QUARTERLYto all officials. If those who fled were to return, they would some-how have to be persuaded that plague was not a threat to them inthe city. If the plague indeed spread by personal contagion, ratherthan by mere proximity to infected houses, this kind of social pres-sure could be relieved if plague could be diagnosed early enoughto remove the sources of contagion before other individuals wereinadvertently exposed. And so the process of diagnosis was to comeunder scrutiny during the month of May.On the first day of the month came a report of the mortal illnessof a twenty-five-year-old female servant of Lord Scaramuzia Vis-conti, who, together with his large household, was lodged in theCastello Sforzaas the duke's guest. Catelano was sent to determinethe cause of the servant's illness. Although he viewed the patient'surine and admitted that it was cloudy or "turbulent," a cause forworry, his report does not indicate clearly whether he actually sawCaterina. Instead he could have made his diagnosis through an in-terview, or case history, taken from members of the household.She had a swelling in the groin area but supposedly was debilitatedby fasting ("ex defectu necessariiregiminis pro vita") andmay havereceived treatment, specifically inducing sweating and opening thelesion in order to evacuate the noxious material causing her illness("putabam eam ex toto evadere per copiosum sudorem et amo-tionem illius eminentie in coxa. ")52Whatever procedure was done,it didn't resolve the problem, for Caterinawas close to death. Per-haps the cloudiness of urine was a furthersign of the concentrationof putrid matter in the body.Surely the ambiguity in this report reflects some measure of thepolitical delicacy of a plague diagnosis inside ahousehold protectedby the duke. All would have to be evacuated or confined to quar-ters. A second case this same day had placed an entire family undersanitaryinterdict because the man had a carbone r pustule in the lat-eralpartof his left eyelid. Though this man's urine was judged notsuspicious and his death occurred after a seven-day illness, nor-mally outside the range considered indicative of plague, "dubiusvalde est," Catelano reported. It is possible that the diagnosis ofplague in this case had little political consequence, so the disparitybetween the physicians' diagnosis and the deputies' decisions couldbe 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. Twodays later, May 3, the servant Caterina died, the concentration orswelling reappearingin the groin. "I do not know what to judgethis other than plague," Catelano reported.Also on May 3 the duke's deputies wrote that a seventeen-year-old boy who lived near the Five Points had manifested a sign ("bu-tato el signo de infection") hat could not be securely identified asplague. Here the victim, not yet dead, was only suffering a fever,and his father, a citadinoand notary for the city, might have beenknown to the duke. "But by the fatherand by many others it is pre-sumed that this case proceeded from the house of that Maestro de'Laghuti"(probablythe same as Legutero noted above for April 23).The deputies' next letter, May 4, noted the boy's death and that ofthe wife of Guido de la Croce, a builder, claiming that they had al-readyinformed the duke about both cases, as plague cases, and thatthey assumed these two and a girl who just fell ill all to have ac-quiredplague in the Five Points. Finally, 5 May, a sixteen-year-oldcleric associated with the church of S. Pietro all'Orto fell ill, withahigh fever and vomiting: "This new caseis presumed to have pro-ceeded because this cleric conversed with a priest named Antonio,of the church of S. MariaPedone, who had practicedin the infectedhouse of Petro Crispo near the Five Points."53All would be takenout of the city, and the deputies grimly noted that cabins wouldhave to supplement S. Gregorio as places for plague victims.54 Thefirst of these three cases had glandular or bubonic swellings in ev-idence of plague.Thus carefully noting the precise chain of infection for each andevery case of plague, the deputies' letters in early May areoptimisticthat careful case tracing and aggressive separation of the healthyfrom the potentially infected would protect the duke's city. Nomore than three people died each day of plague, and all "proceededfrom contagion, taken in that neighborhood of the Cinque Vie. In

    S3Ibid., no. 225, 5 May 1468: "Questa matina siamlo avisati che Martedi prox. pas-sato al Clerico del preyto de la Clesia de S.to Petro al orto de questa vra. Inclita Citade etade circa anni xvi asalto el vomito cumn a febre grande: Nuy subito gli havemomandato el Catelano quale per il suojudicio lo mete suspecto. Questo novo caso se pro-sume sia proceduto per havere havuto esso clerico conversatione cumnuno preyto An-tonio beneficiale de la Clesia de S.ta Maria pedone el quale praticava in la casa de PetroCrespo infect. vicina ale Cinquevie. Havemnoordinato de miandarliquesta prox. nottefuora de questa prefata vra. Citate."54MS, 2, no. 12.

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    RENAISSANCE QUARTERLYother places," the Health Magistrates argued, "thereis presently nostain [of plague] whatsoever." Interestingly, the duke didn't see thisinformation so optimistically. He answered the bulletins May 5:

    . . we understand from what you wrote in your [letter] yesterday aboutthe progress plague makes and of those who are ill, and we are much dis-pleased with this. It appears to us that you have not applied every remedyand good provision. Thus we wish and charge you to summon the entireCollege of Medicine before you along with Maestro Benedetto da Norciaand all the court physicians, and even all the gentlemen (zettilhoiniui)elected to [stand guard] at the gates. And all of you together should con-sider and deliberate upon all of the best provisions for remedying thisplague. We want to hear by this evening what you have arranged concern-ing this. It truly surprises us that you always assert that you need moneyto make provisions, etc., for you have not given us information as to thesums needed to make these provisions. We will make all disbursements asthey appear necessary to us.55

    The deputies were clearly in a difficult position, having to defendeach step in order to receive money to operate and dealing with aduke who suspected that they were not performing their dutieshonestly.From their own perspective the deputies could argue that theywere being cautious to a fault (in fact they were later faulted injustthis regard). Even in the cases where the sick person's urine did notyet reveal plague to the physicians and where no external mark orsigns had yet appeared on the individual's skin, the families werecautiously isolated or exiled. Insofar as they regardedmedical coun-sel crucial to the outcome of plague control and believed plague tobe spread by contagion, the duke and the deputies agreed in early

    sSforzesco, CartcLqgiolitcrno, 884, 5 May 1468:"havemo Intesoquantone scrivetiper la vra. dil di de heri del progresso fa la peste et de quelli sono morti, del che nehavemo preso dispiacereassay, parendoneche per nientenon se gli habiiad mandarede ogni remedio et bona provisione. Et impero voleimoet cosi vi commiettiamochevoy debbiatihaveretuttoel collegio dimedicidavuy et cosi MaestroBenedicto da Nor-s[i]a. Insieme con tutti li altrimedici de la corte et Item tutti li zentilhomini ellectaperle porteet tutti Insieme debbiatipensareet deliberare utte quellebone provisioni chesiano remediatorieadlapeste. Inmodo che questaseranel mo[do] zonzere li possiamoIntenderequelladeliberationegli haveritifacta.Ben ne maravegliamodi facti vostrichevuy sempre allegatichese havesti dinariprovediesti,etc. Et dal altrocantonon ne avi-sati che summiagli bisognariasiche avisatine de li dinaribisognarianoad farequesteprovisione perchestipendolo faremopoy quello ne parrera ssereel bisogno. Abiate-[grasso]."At the same time Galeazzo Mariasummioned he lawyers andjudges to adebate, chargingthem to deliberatethe terms of the peace treatyhe was negotiatingin Rome. It is interestingthat this well-educatedyoung duke appeared o value pro-fessionaladvice highly.

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    May. The deputies of necessity had to listen to physicians' reflec-tions on individual patient cases and trust to some degree their finaldiagnoses. The duke, instead, could view all failures to contain theplague 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' honestyand dedication to thorough plague control, as later examples willshow. But for the deputies, the problem in May became one ofdealing with the medical information that reached them. Two dif-ferent sets of doubts could confound their simple causal synthesisthat plague spread by human-to-human contact: cases falling out-side the geographical boundaries the deputies accepted and casesobscuring the medical boundaries used to find a death unarguablydue 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 de-fend their actions before a skeptical duke, the deputies and SecretCounsel had to shift the blame for procedure failures to the phy-sicians' inability to give clear guidance, or to the noncompliant ac-tions of private citizens who evaded public health controls. Theother option before them, of course, was a serious reevaluation ofthe contagion model on which all theirpracticeswere based. Brieflythe deputies entertained this possibility that plague was not spreadby person-to-person contacts: "But if plague has proceeded fromother influences, as from intemperance of the air, it will be neces-sary that the charity and grace of God work [with us]. We haveheard loud murmurings about us and worry that some of thesecomplaints will reach your Excellency's ears. . . . We are not hereto displease nor to injure any living soul. We only stand by to doyour orders and that which we know will be to the good health ofthis city."s6 But because doctors were at least partially committedto the notion of contagion as cause of new plague cases, abandoningbelief in the efficacy of contagion practiceswould have left the dep-

    56MS, 2, no. 19, 8 May 1468: "Se questi casi procedano da contagione non dubitav. S. che se gli fara bona provisione in modo la Cita se adiutara: Ma quando procedes-sero da altro influxo, o per intemperie de aere, bisognieria che la misericordia et gratiade dio se operasse. Nuy Intendemo se fano de grande murmuratione et existimamo chemolti verrano a le orechie de v. Ex.tia a fare li rechiami et volerne sindicare dicenmocossi, che nuy siamo qui per non fare dispiacere ne iniuria ad persona che viva. Soloatendiamo a fare quanto ne ha imposto V.S. et quello cognosceremo essere bene et sa-lute de questa Citate."

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    uties in an even more precarious position. Hence the deputiesmoved more committedly to document the contagious path ofplague.The extent of the inquisitorial investigation by the health offic-ers, done to document the contact transmission of plague, can beillustratedby a longish example. Giovanni Catelano reportedanewcase of plague on the morning of 7 May. Antonio da Robio, anineteen-year-old youth who worked in the barber shop of Gio-vanni Pietro de' Mori, fell ill with a high fever, no "signs" yet ap-parent.The shop in Piazza della Corte was across from the windowof the Maestri dell'Intrate(customs officials), where a few caseshadoccurred. 7 This discovery was a relief to the deputies becauseit ex-plained a case that otherwise demanded a very cautious, measuredreport. Young Antonio actually lived elsewhere in the city, acrossfrom the house of a Baldesare Capra (near the church of S. Sim-plicianino; see map). "Until now," they admitted, "we couldn'tfind out where he had acquiredthe disease," andthey suspected thathe had bled or had otherwise come into contact with an infectedperson. Despite their best efforts they had not been able previouslyto trace the path of plague from person-to-person. 8The area nearthe barbershop was clearly infected: Lucia, the fourteen-year-olddaughterof a certain Giulielmo di Teoldo, died there this day. Cat-elano or his superiorsjudged this a caseof plague even though Luciashowed no external sign whatsoever, merely because she had goneinto the Cinque Vie and talked with people who subsequently fellill with plague. Yet a third plague death was explained by carefulinvestigation of her itinerary, allowing the deputies to concludethat the Cinque Vie was still the principal focus of plague infectionin the city. Contagion was reaffirmedalong with the geographical

    57Ibid.,no. I5, 7 May 1468. The health officers and customs officials were tradi-tionallyadversariesduringplaguetimes, the latteroften tryingto postponedeclarationof plague becauseit would reduceincome and commerce to the city. In the view ofhealthofficers, the delays put the community at further risk. See Albini, 97.58Presumably the deputieswere informedof this new case on the day they wrote,which makes the "untilnow [fin qui]" statementproblematic.The next day (MS, 2,no. I6) they wrote that the barber[Antonio?]"ha butato forael signale"but that "sofar[fin qui]" they had not traced the origin of the case. The text is otherwise ambig-uous. No reportof Baldasare's llness (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 locationor perhapsbecausehe was sociallyimportant.The othercasereportedthisday, in thisletter,mentions the immediateneighborsof the infected,Count Giovanni Bonromeoand bankerMarcoda Galara(MS, 2, no. I5).

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    concentration:"only one new case appearedtoday [14 May], whichwe believe was produced by contagion, because it occurred in theinfected district."59The deputies' letters cheerfully affirm the wisdom of their pro-cedures, revealing to the duke the actions that they had taken in theimmediate past, how the evidence confirmed their working con-tagion model, and ending with assurance that they would continueto do everything possible to arrest the progress of plague. Insofaras they reported "evidence" for contagion buried in the cases onwhich action had already been taken, they had been withholdingfrom the duke evidence that didn't immediately fit the pattern ofexpectations. Cases that eventually became explicable were re-ported at length. In all of this, it is not clear whether the deputieswere deceiving the duke or themselves. Physicians making the di-agnosis with which they all had to contend became critically im-portantinformation, and, as we shall see, the health commissioner,Hector Marchese, claimed that it was atjust this time he began toworry about the process of medical diagnostics. Beginning in mid-May, Hector began to send the duke yet another copy of the dailydeath and illness report, so that the duke received three or morenearly identical bulletins each day At this point the deputies alsobegan to send separate reports of new cases, distinct from the deathreports.Responding to the rather dramaticincrease in the number of of-ficial plague cases reported, the mass exodus began around 8 May.At this time two little girls fell sick with plague, daughters of oneCristoforo da Cazeniga, who lived in the district of the Porta Ver-cellina, the neighborhood of S. Pietro della Vigna, the parish of S.Mariaal Circo. They lived near enough to houses infected back inMarch that no worry presented (see map). And two others died inpreviously infected houses. But Hector and Catelano had one morecase to explain. The parish elder in S. Maria Pedone reported ill awoman who was interrogated unsuccessfully. Not only couldMarchese and Catelano find no evidence of the path of contagion,the woman died during the questioning, redoubling their suspicionthat plague was the cause. A personal advisor to the duke restatedthe health deputies' message in away unburdened of contagion the-ory: "things are not without danger now that [the plague] pops up

    59Ibid., no. 28.

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    RENAISSANCE QUARTERLYin so many different places. . . . Most of all you must protect your-self."6o It was a message Galeazzo Maria related to his mother inearly June, begging her not to stay in Cremona, where plague be-haved the same capricious way.6' It was also a message that ques-tioned the spread of plague by contagion alone. But at this timeGaleazzoMaria was preoccupied with his ambassadors'negotiatinga peace treaty in Rome and with upcoming wedding plans, so hispersonal secretaries and servants concentrated more on the prob-lems created by flight from the city.62Missing links in the chain of infection were a type of problemHector Marchese and the health magistrates had to explain defen-sively to the duke, for the latter would conclude that officials weresimply not diligent enough. In turn they tended to fault the phy-sicians who could not seem to diagnose plague early enough in itscourse for implementation of appropriate precautions. From thephysicians' perspective, it was sometimes difficult to diagnoseplague even aftera person died. For example, atjust the time panicwas greatest, on I6 May, Constantina, the five-year-old daughterof Maestro Iacopo da Firenze, died with "many malignant worms,and abdominal swelling and pain, after a six-day illness." Iacopowas both asurgeon andananatomist, and he had worked with Cate-lano in the great plague of I45 as official physicians to the Sanita.Thus he, too, had extensive experience diagnosing and treatingplague. His daughterdied of an illness common among young chil-dren. But on 31 May, Ambrogio, twenty-year-old servant of Ia-copo, fell ill with pestilential fever, a bubo in the right axilla, andwith a profuse nosebleed, according to the judgment of Iacopohimself and Maestro Dionysio de' Cerruti, another surgeon. Thiscase was unavoidably listed among the new "suspicious" cases thisday, even though the deputies made an exception and allowed the

    60Ibid.,no. 21, from GiovanniGiapanoto the duke: "non me paresiano senzaper-icolo vedendola[peste]saltare n tantidiversi lochi. E pero fidelmente ricordo a V. S.primael conservare a personada la quale depende la universalesalute, non solo dequestasua patriama de tuta Italia."6'Ibid., no. 354.62Ibid., no. 22, FrancescoMaletesta, io May, worries that citizensfleeingfrom Mi-lan to other cities in the ducato will bring plague with them; ibid., no. 21, JohannesGiapanus warns the duke that he should consider envoys from Milan, as well as otherplague spots, dangerous, and that it is important for the duke to preserve his ownhealth, "da la quale depende la universale salute non solo de questa sua patria ma detuta 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 allof the other suspects. Catelano added to the report, "But I amamazed that the urines are laudable in this case; I expect, however,the appearanceof a rash [morbilorum, r measles]."63Infections occurring in the houses of physicians inevitablyevoked some of the flexible rhetoric in plague diagnostics, but mag-istrates' own criteria often overruled the physician's. For example,a servant of Maestro Girolamo da Lode, longtime member of thecollege, on I8 May was ill with an "aposteme" in his right groinand had "spasmotic tetanus with parafrensy."64The boy was atdeath's door, and the deputies doubted that this could be explainedany way other than plague, for another boy in the household hadrecently died. "For greater security I [probably Hector] have hadthe house closed up, and that which he [probably Girolamo] wantsto hide by alleging that these arenot suspicious [cases] soon will beclearlyseen. This is not a new case becausehe [the servant] was con-taminated, as your Excellency can see."65 The duke's personal in-formant, Giovanni Giapano, spelled out the path of contagion, cit-ing the earlier death fifteen days before as a plague case "eventhough he [the physician] denies it" and because the physician wentto visit his father at the hospice "il Seraxino," near the castello. Thephysician was ordered to stay in his house and had done so, at leastthrough one whole day, "even though he has tried [to escape] manytimes . . . saying that this is not a suspicious case." Giapano alsoenlarged upon the duke's theme of mendacity among public offi-cials, asserting that Maestro Girolamo had not declared this illnessin his household, concealing it for several days. Persuaded, prob-ably by Giapano, that the physician's motives were malicious, the

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

    frenesia,moriturusiam iam." Hieronymus de Casetis de Laude[Lode] matriculatedin the College of Medicine 12 November 1432; see Bottero, 112. Bianca Maria was in-formed of the servant's death as well; see Sforzesco, Cartcggiointerno,884, 22 May 1468,Giovannida Petrasancta o BiancaMaria.Giovanniavoids the word "contagion,"pre-ferring "contaminatio."5Ibid.:"Permagioresecureza 'ho fecemoserraren casaet cuossiquellocoleva oc-cultarecon allegarenon fuosse sospecto hora si se apertamentedimonstrato. Questonon e caso novo peressereluy contaminato n quelo Inodo puo vederevra. Sig[nor]-ria."

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    deputies said that they had decided to send Hieronymo and his en-tire family to S. Gregorio, the lazaretto, "where he can tend to theothers."66The Boundaries of Contagion Practices

    By late May Galeazzo Maria began to question the rationale forthe contagion practices that health officers defended. The responseof an old, faithful servant of Galeazzo Maria's father and grandfa-ther may have been prompted by the duke's growing concern: "Idon't recall ever seeing such ordinances [during the time of] youruncle, Filippo Maria," Antonio Canobio wrote to Galeazzo Mariaon 25 May, but there were more recentprecedents.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 thedeputies likened to a flame,68Galeazzo Mariahad ordered a full in-quiry into the causes of plague, summoning (from a safe distance)the opinions of the physicians in the College of Medicine, from hisdeputies and Secret Counsel, and from Hector Marchese himself. 69Two things worried the duke: was not the plague contagious? and,if it was, why was the trail lost in May?The college responded witha consiliumtaking into account Milan's relation to astral events thatspring but blaming the excessively humid fall and early winter forthe appearance of acute fevers, though without any explanationwhy transmission of the disease progressed steadily through thespring. 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 Hy-eronimo 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] aken to Sancto Gregorio,and thus it was done." This isn't quite true. They next say that there were "other pen-sioners" in this house who remained separated from the infected, so, cautiously, theywere quarantined in the house so that they could not get out. For fifteen days they werehale and hardy [saniet salvi]. Nevertheless, two little girls died the previous night (May24), so all the rest of the household were shipped off to S. Gregorio. The deputies wereoffering the best possible interpretation of their actions.67E.g. Ibid., no. 48. That exemplar no longer survives with the letter, nor have Ibeen 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 con-vocation probably did not take place untilJune. The undated consilium appears in MS,I, no. 26, titled "Responsio Collegii Phisicorum et eius apparere super interrogationefacta 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 problemwith his own strict adherence to contagionism:During the first wave, about the fourteenth of March, in S. Vittore, andfollowing house by house from those of Lampugnano, I reflected fromtime to time about the process and concluded it must be by contagion [thatplague spread]. This was until the third of May, when the household ofScaramuzia Visconti was infected. From there it proceeded into diversehouses and parishes, and I lost the path of contagion. And since I anticipatedyour question, I went around with Catelano and other physicians of thecollege, visiting the houses with them so that I could understand what washappening. I wanted to know why so many [cases] were seen by a physicianon the day that they first became ill, but the physicians, not fully recog-nizing their illnesses, held the [news] two or three days before declaringthe case one of plague. The answer I had from Catelano and the others wasthat in the beginning they didn't know, and couldn't know, because theylooked 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 feversfor which, in a short time, the urine later changed and showed the case tobe pestilential, and then they had to change their notification. At this pointwe [at the office of the Sanita] went to visit the ill person and decide thetruth about who was plague-stricken. Now as to the cause [of plague] theyagree that we should doubt the influence of some planet or other. But, yourexcellency, even until today I do not lack either the conviction or the hopethat, God willing, [our approach will work].7"

    Marchese then cited his experiences with plague in 1464, 1465, andin the previous year, expressing faith in the efficacy of currentplague procedures, if applied diligently. During late May, he andthe 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 Victoreattine6 [?] et sucesive in casa di quili da Lampugnano et procedendo di casa in casa ditempo In tempo, ho miso la mente trovava et Intendeva il processo essere contagioneper fino al tertio giorno di mazo, quale fece lo asalto in Casa dil quondam scaramuzaviceconte, 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 ilCatellano et con alcuni altri medici collegiati digando io verso di loro donde potevenoIntendere procedese questo, perche molte case quale erano nele [?] mane di li su-prascripti medici non havevano Inteso le loro malatie et teneveno nele mane duy et trigiorni uno amalato possa ala fine si ritrovar pestiferi. La risposta ch'io haveva dal Ca-tellano et da loro e questa: che neli principii loro non cognoseneno ne poteveno co-gnosere sopra le urine perche che non visitaneno ne tochaveno ne ancora tochano nevisitano, dicono havere ante nele mane alcuni di alcune febre che in pocho di tempose cambianeno le urine et monstraveno subiugale et pestifere et li remeteveno nele manedi lo officio donde havemo che visita et chi tocha ad dicernere la veritate. Et questoconcoreno et dubitano non sia Influentia di alcuni pianeti. ..."

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    physicians' tardy diagnoses, further emphasizing the duke's previ-ous conviction that the contagion model best fit the facts.7,EarlyJunebrought a reprievein the number of new plague cases,as it usually did in Milanese plagues.72Galeazzo Maria could haveseen these events as a measure of the success of public health inter-vention had not his adherenceto contagion practices begun to wa-ver. As he hadpredicted, his mother became ill in fleeing Milan forCremona. She wrote 30 May to praisehis powers of divination. Re-sponding on 2 June, the Duke argued that his deduction that shewould 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 thatyou would not carry it there," bringing such a huge retinue. Buthe avoided altogether the delicate issue of contagion, which couldimplicate some member of her household. Galeazzo Maria receivedletters from her doctors that she was improving but cautioned herto be especially careful, "because your every illness is my illness."In other words, this was a period in which Galeazzo Maria was de-pendent upon what the good doctors could do, and a time in whichhe was abandoning hope for