The Greatest Benefit to Mankind

RELIGION

Medicine and religion intersected at many points. Conventional histories of medicine still retail the view that the Church arrested medical progress, for instance, by supposedly banning dissection. Some ecclesiastics did indeed disparage medicine – St Bernard of Clairvaux (1090–1153) asserted that ‘to consult physicians and take medicines befits not religion and is contrary to purity’ – and it was a popular gibe that ubi tres physici, ibi duo athei (where there are three doctors, there are two atheists); but in general such judgments miss the mark. Medieval hospitals have been criticized for their religious ethos, but without the Christian virtue of charity would such hospitals have existed at all?

The Church’s position was clear: the divine was above the temporal. Sometimes the Lord’s will was to punish sinners with plagues; sometimes it was man’s duty to preserve life and health, for the glory of God and the salvation of souls. But the body was to be subordinated to the soul, and healing, like every other temporal activity, had to be under ecclesiastical regulation. Thus in the case of the dying, it was more important that they should be blessed by a priest than bled by a doctor. Concern for salvation occasionally led to suspicions being voiced against Jewish doctors: the Lateran Council of 1215 forbade practitioners not approved by the Church from attending the sick, but this applied only on paper, for the highly valued Jewish doctors were everywhere, especially in Spain.

Monks and clerics, for long the only body of learned men, commonly practised medicine, while in the northern European universities medical students often entered minor holy orders. Petrus Hispanus (Peter of Spain c. 1210–77), whose Thesaurus pauperum [Treasury of the Poor] was popular despite its recommendation of pig shit to stanch nosebleeds, even became Pope in 1276 as John XXI. (He died a year later when the roof of a palace he had built collapsed; one trusts he was a better doctor than architect.) Various ecclesiastical regulations were passed covering medicine; the aim was not to curb it but to uphold the Church’s dignity and prevent clerics developing lucrative sidelines which would seduce them from holy poverty and divine service. Thus when the Lateran Council of 1215 forbade clerics in higher orders from shedding blood, this was not (as often interpreted) an attack on surgery: it aimed, not unlike the Hippocratic oath, to detach the clergy from a manual and bloody craft. Clerics could continue to practise healing but not for gain. Nor did the Church authorities prohibit dissection: in 1482 Pope Sixtus IV informed the University of Tübingen that, provided the body came from an executed criminal and was finally given a Christian burial, there was no objection to human anatomy.

The Benedictine rule states that ‘the care of the sick is to be placed above and before every other duty, as if indeed Christ were being directly served by waiting on them’; hence it is no surprise that monasteries became key medical centres, more important than universities prior to 1300. As well as offering shelter for pilgrims, most had an infirmary (infirmarium) for sick monks. Separate hospital facilities were founded for the general public.

Healing shrines flourished, and scores of saints were invoked – rather as in Egyptian medicine, each organ of the body and each complaint acquired a particular saint. Supplanting the pagan Asclepius, Damian and Cosmas became the patron saints of medicine. Brothers living in Cilicia (Asia Minor) around the close of the third century, they became celebrated for their healing powers. Their martyrdom under Diocletian is stirring stuff: despite being burnt, stoned, crucified and sawn in half, they survived, perishing only after decapitation. The pair appear in the heraldry of barber-surgeon companies, and churches were dedicated to them, often claiming to house their remains in fine reliquaries. Their chief medical miracle credits them with the first transplant: they amputated a (white) man’s gangrenous leg and grafted in its place that of a dead Moor. In many paintings depicting this scene, the patient, with one leg white and one leg black, lies supine as the spectators stare awestruck upon the miracle.

In addition to this pair, St Luke or St Michael might be called upon for all manner of illnesses, but other saints were specialists: St Anthony was invoked for erysipelas (St Anthony’s fire); St Artemis for genital afflictions, St Sebastian for pestilence. St Christopher dealt with epilepsy, St Roch protected against plague buboes (he had visited many sufferers on missions of mercy, fell sick himself, then was healed by an angel); St Blaise was good for goitre and other neck complaints, St Lawrence for backache, St Bernardine for the lungs, St Vitus for chorea (St Virus’s dance) and St Fiacre for sore arses. St Apollonia became the patron saint of toothache because all her teeth had been knocked out during her martyrdom, while St Margaret of Antioch was the patron of women in labour. Out walking, she had encountered a dragon, which swallowed her whole. In its stomach, she piously made the sign of the cross; this materialized into a real cross, growing until the dragon burst open, thus delivering the saint.

Healing shrines developed a great range of relics, pious images and souvenirs. Some, like Bury St Edmunds or Rocquemadour in the south of France, attracted pilgrims by the thousand. The blood of St Thomas a Becket cured blindness, insanity, leprosy and deafness – and ensured Canterbury’s popularity. In Catholic Europe, many medieval shrines continue to this day.

Certain diseases, for instance the much-feared epilepsy, assumed supernatural connotations and cures; Hippocrates would have turned in his grave! Treatments for the falling sickness involved a mishmash of folklore, humoral medicine, sorcery, pagan beliefs and pious healing. John of Gaddesden (1280–1349), physician to Edward II and compiler of the encyclopaedic Rosa anglica medicinae [The English Rose of Medicine], recommended reciting the gospel over an epileptic patient while bedecking him with peony and chrysanthemum amulets or the hair of a white dog. The folk conviction that mistletoe cured the falling sickness was given a sacred rationalization: keeping watch over his father’s flocks, the young King David saw a woman collapse in a fit. When he prayed for a remedy, an angel appeared to him, announcing, ‘Whoever wears the oak mistletoe in a finger ring on the right hand, so that the mistletoe touches the hand, will never again be bothered by the falling sickness.

Mistletoe was also used in other ways against epilepsy. In central Europe, the stalk was hung round children’s necks to prevent seizures, while in Scandinavia countryfolk carried a knife with a handle cut from oak mistletoe. In the mid seventeenth century, the leading experimentalist and founder-member of the Royal Society, Robert Boyle, was still endorsing pulverized mistletoe: ‘as much as can be held on a sixpence coin, early in the morning, in black cherry juice, during several days around the full moon’. The pious Boyle believed in religious cures, but sought their scientific basis.

HOSPITALS

Medieval hospitals were religious foundations through and through. Those planted in the West had originally been small and mainly for pilgrims; their late medieval successors were often more impressive. St Leonard’s in York had 225 sick and poor in 1287; still larger were the civic hospitals of Milan, Siena and Paris. In Florence alone, a city of some 30,000 inhabitants, there were over thirty foundations by the fifteenth century. Some had only ten beds, others hundreds. In England hospitals and almshouses totalled almost five hundred by 1400, though few were of any size or significance. London’s St Bartholomew’s dates from 1123 and St Thomas’s from around 1215. At Bury St Edmunds six hospitals were endowed between 1150 and 1260 to cater for lepers, pilgrims, the infirm and the aged.

Small hospitals were essentially hostels or hospices lacking resident medical assistance, but physicians were in attendance by 1231 at the Paris Hôtel Dieu, next to Notre Dame, and Sta Maria Nuova in Florence was gradually medicalized: from twelve beds in 1288 for ‘the sick and the poor’, this ‘first hospital among Christians’, as one Florentine patriot called it, expanded by 1500 to a medical staff of ten doctors, a pharmacist and several assistants, including female surgeons. Although catering largely for the indigent, it had eight private rooms ‘reserved for the sick of the higher classes’. Within hospital walls the Christian ethos was all-pervasive.

In hospital expansion the Crusades played their part, since crusading orders such as the Knights of St John of Jerusalem (later the Knights of Malta), the Knights Templar, and the Teutonic Knights built hospitals throughout the Mediterranean and German-speaking lands. By the fourteenth century non-military brotherhoods, such as the Order of the Holy Spirit, were also running infirmaries from Alsace to Poland, while the Order of St John of God appeared in Spain in the sixteenth century, building insane asylums and putting up about 200 hospitals in the New World.

LEARNED MEDICINE

The great age of hospital building from around 1200 coincided with the flourishing of universities in Italy, Spain, France and England, sustained by the new wealth and confidence of the High Middle Ages. Paris was founded in 1110; Bologna in 1158; Oxford in 1167, Montpellier in 1181, Cambridge in 1209, Padua in 1222 and Naples in 1224. The universities extended the work of Salerno in medical education. By the 1230s Montpellier was drawing medical students from afar; there, as in Paris, Bologna, Oxford and other centres, medical teaching initially developed informally, but teachers later banded themselves into an official faculty.

There were some differences between the clerically dominated universities of the north like Paris, Cologne and Oxford, where the theology faculty was supreme, and the more secular ones of Montpellier and Italy, where arts and law faculties led; but all had much in common. The Bachelor of Medicine (MB) took around seven years of study, including a preliminary Arts training; a medical doctorate (MD) was awarded after around ten years’ study. Hence there were hardly swarms of medical students: Bologna granted 65 degrees in medicine and only one in surgery between 1419 and 1434; Turin a mere 13 between 1426 and 1462. The single big school and true centre of excellence was Padua, where medical students comprised one tenth of the student population. Its medical faculty was unusually large, numbering 16 in 1436 – Oxford had only a single MD teaching.

Following the model established in universities at large, medical education was based on set books, usually parts of the Articella and Avicenna’s Canon, expounded in lectures. It was also heavily influenced by the new Aristotelianism associated with Thomas Aquinas (1226–74) and Albertus Magnus (1200–80). A Dominican monk who taught at the new university of Cologne, Albert was wrongly credited with many medicinal recipes and occult treatises, as well as with the De secretis mulierum [On the Secrets of Women], all of which blocked his canonization until 1931.

After perhaps seven years’ study beyond the Arts degree, doctoral graduation rested on having attended the requisite lectures, disputations and oral examinations and – at some universities, including Bologna and Paris – on having worked under a physician (such clinical experience had to be acquired extra-murally). From about 1300 at Bologna and a generation later at Montpellier, university requirements further demanded that students attend a dissection, to supplement traditional anatomical lessons on dead animals. The academic justification of a medical education lay in the acquisition of rational knowledge (scientia) within a natural philosophical framework. Medical professors aimed to prove that their discipline formed a noble chapel of the temple of science and philosophy; the learned physician who knew the reasons for things would not be mistaken for the hireling with a knack for healing.

Renaissance humanists and subsequent historians have sneered at medieval academic medicine for its Galenolatry and its abstract disputation topics (‘Can sleep be harmful?’). But formulaic teaching was unavoidable in an age when books were few. And if much of the knowledge seems rather formal, this is because the student had to understand the medieval forerunner of what is now prized as ‘basic science’: the theory of the physical world and its laws and purposes. Grasp of universal truths was needed to comprehend individual cases, and the ability to reason and cite chapter and verse raised the true physician above the empiric.

Graduates got the pick of the patients; princes and patricians in Italy, France and Spain welcomed cultured doctors who could explain the whys and wherefores. The duties of physicians in the service of King Edward III of England were clearly laid down:

And muche he should talke with the steward, chamberlayn, assewer, and the maister cooke, to devyse by counsayle what metes and drinkes is best according with the Kinge.… Also hym ought to espie if any of this courte be infected with leperiz or pestylence, and to warn the soveraynes of hym, till he be purged clene, to keepe hym oute of courte.

The learned physician claimed, in the Hippocratic manner, to prevent disorders or restore health by dietetics and drugs. For that he would need to form a diagnosis. Feeling the pulse and scrutinizing urine (uroscopy) were routine, and the doctor’s consilium (advice) would be a personal prognosis based on a patient’s history. Drug prescriptions were also personalized, involving compound mixtures (polypharmacy), often called ‘Galenicals’.

Highly prized was medical mathematics, which sought to achieve an understanding of the significance for health of the motions of the heavens, in a tradition going back to the Hippocratic Epidemics and embracing subsequent developments in Ptolemaic astronomy and astrology. Following Galen, disease was enumerated as involving sequences of ‘critical days’ when an illness would reach crisis point and then either subside or prove fatal. The physician on Chaucer’s Canterbury pilgrimage was proud of his astrological learning:

With us ther was a DOCTOUR OF PHISYK,

In al this world ne was ther noon him lyk

To speke of phisik and of surgerye;

For he was grounded in astronomye.

He kepte his pacient a full greet del

In houres, by his magik naturel.

Wel coude he fortunen the ascendent

Of his images for his pacient.

He knew the case of everich maladye,

Were it of hoot or cold, or moiste, or drye,

And where engendred, and of what humour;

He was a verrey parfit practisour.

Medical astrology might require arcane and labyrinthine calculations, but there were handy charts to illustrate planetary influences over the organs of the body and their maladies. Princely courts often housed a physician-astrologer, though it could prove a risky trade: the physician John of Toledo (d. 1275) was accused of dabbling in necromancy, and thrown into prison.

Zodiacs and nativities were also used to ascertain the right time for blood-letting. Recommended in spring and the beginning of September, its benefits, according to the Salernitan Rule of Health, included sound sleep, toning up the spirits, calmness, and better sight and hearing. Bleeding was left mainly to surgeons and barber-surgeons, who also cupped, pulled teeth, leeched, gave enemas, curetted fistulas, applied ointments, drained running sores, sutured wounds, removed superficial tumours and stopped haemorrhaging. Descriptions of trusses and eyeglasses began to appear in the thirteenth century.

Dietetics, by contrast, was the main therapeutic recourse of the physician regulating lifestyle in accordance with the six non-naturals. Spurred by the revival of international commerce, pharmacy also developed, especially in Venice, where drugs imported from the East were traded in large stores (apothecai), which came to mean a druggist’s shop.

Relations between physicians and surgeons were not always plain-sailing, especially with eminent surgeons like Henri de Mondeville, Guy de Chauliac and John of Arderne (c. 1307–70) laying claim to learning as well as a good eye, a steady hand and a sharp blade. According to de Mondeville, ‘it is impossible to be a good surgeon if one is not familiar with the foundations and general rules of medicine [and] it is impossible for anyone to be a good physician who is absolutely ignorant of the art of surgery.’

Among the famous early surgical writers was Lanfranc of Milan (c. 1250–1306). Italian by birth, he settled in Paris where he wrote his Chirurgia magna, an expansion of his more popular Chirurgia parva. They were both translated into French, Italian, Spanish, German, English, Dutch and Hebrew. The Grand Surgery is divided into sections on general principles, and on anatomy, embryology, ulcers, fistulas, fractures and luxations, baldness and skin diseases, phlebotomy and scarification, cautery and diseases of various organs. There is also a lengthy section on herbs and pharmacy. Lanfranc was valued by his distinguished successors, de Mondeville and de Chauliac.

Henri de Mondeville (c. 1260-f. 1320) was born in Normandy, studying at Montpellier, Paris and Bologna. Travelling widely, he spent some time as a military surgeon to the French royal family, and lectured in surgery and anatomy at Montpellier and Paris. He planned his Cyrurgia (begun in 1306 but never completed) along traditional lines, opening with anatomy and moving on to wounds. Attention was paid to the contentious topic of wound treatment. Mondeville advocated simple bathing of wounds and immediate closure, followed by dry dressings with minimal loss of flesh or skin. His preference was for dry healing without pus formation, a view contradicting Hippocratic wisdom but already advocated by Hugo of Lucca (c. 1160–1257) and his disciple, Theoderic (1205–96), who had boldly maintained in his Chirurgia (1267) that ‘it is not necessary that pus be formed in wounds’.

This new approach met opposition from supporters of conventional wound salves: plasters and powders designed to promote suppuration; since Greek times it had been taught that certain types of pus (known as ‘laudable pus’) were beneficial, conveying poisoned blood out of the body. The Salernitan school had thus recommended keeping wounds open to allow for suppuration and healing per intentio secundam (by second intention), from the base of the wound up.

The most prominent surgeon of the next generation was Guy de Chauliac (1298–1368), educated at Montpellier and Bologna. His great work, the Chirurgia magna, was fully comprehensive, covering anatomy, inflammation, wounds, ulcers, fractures, dislocations and miscellaneous diseases belonging to surgery. An astonishing exercise in surgical erudition, it contains no fewer than 3299 references to other works, including 890 quotations from Galen. This parade of sources was calculated, since Chauliac was concerned to show surgery to be a learned art:

The conditions necessary for the surgeon are four: first, he should be learned, second, he should be expert: third, he must be ingenious, and fourth, he should be able to adapt himself. It is required for the first that the surgeon should know not only the principles of surgery, but also those of medicine in theory and practice.

Chauliac’s Chirurgia was translated into several languages. In the pus bonum et laudibile debate, he did not exactly take sides, though he appears to have been hostile to traditional wound salves, judging they did more harm than good. The work also contains fascinating details about his own times, including first-hand reports of the Black Death, descriptions of surgical instruments and operations, and his often damning judgments on his contemporaries. Like most medieval practitioners, he offered a pot-pourri of Hippocratic treatments and ones of a magico-religious flavour. Epileptics, for instance, were to write in their own blood on a piece of parchment the names of the Three Wise Men, and to recite three Pater Nosters and three Ave Marias daily for three months.

The most distinguished English surgeon was John of Arderne, who served under John of Gaunt in the Hundred Years War and produced a Treatment of Anal Fistulas. For this operation, his technique was to place the patient in the lithotomy position. Four ligatures were taken up through the fistula, and their ends, drawn down through the anus, were knotted to stop the bleeding. Next, he pushed one grooved instrument through the fistula into the rectum, where it made contact with another. He then made a bold cut with his scalpel to remove the whole intervening segment, and stopped the bleeding between the ligatures with a hot sponge. The wound was cared for by cleaning and the patient was given daily enemas.