E.J. Mayeaux, Jr., M.D.
Associate Professor of Family Medicine
Clinical Associate Professor of Obstetrics and Gynecology
Louisiana State University Medical Center Shreveport, Louisiana
As one contemplates the advancements of modern medicine, one must wonder at the people and methods used in medicine in the Middle Ages. Their drives for health, long life, and freedom from pain seem much like our own motivations today, but their approaches and ideas on medicine and life in general were completely different. Let us look at our history of medicine, how it affected the people and ideas of the times and how it was affected by them.
When looking at medeival medicine, one immediately becomes aware of the importance of the "teaching of the ancients" to the medieval mind. The two most famous of the "ancients" were Hippocrates and Galen. We must first understand their teaching before we can go on to how medieval medicine worked.
Hippocrates of Cos is often hailed as the father of medicine. He was a Greek physician who lived around the 5th and 4th centuries B.C. Except for a few brief references by Plato, we have very little reliable information on the man himself. However, what are important are his teachings. Although he did believe in "humors" and "foul vapors" which caused disease, many of his teachings are in tune with what we know to be true today. Hippocrates believed that nature healed all wounds and the physician was a modifier of that natural healing. He taught that medications could produce a countereffect to the symptoms of a disease, "opposite through opposite".
He discussed medical subjects freely and without an air of mystery, scorned all pretense and tried to acknowledge his limits and failures. Although public opinion during his time condemned dissections of the human body, Hippocrates did perform them to a limited extent. He also emphasized the observation of external signs and symptoms in establishing diagnoses.
In addition, Hippocrates dealt well with fractures and was a master in the use of splints. He even treated fractures of the skull with trepanning (removing a circular area of bone) and bade his students to be careful not to mistake suture lines for fractures.
Most of all, Hippocrates was a good observer. This can best be demonstrated by his "Aphorisms" or his advice to physicians:
These are the work of a down to earth observer. The writings of Hippocrates were taught and written about for centuries to follow. There is one critic, however, who had the greatest impact on medieval medicine.
One man considered himself the successor of Hippocrates. He was Claudius Galenus whom we today know as Galen. Of himself, Galen wrote, "No one before me has given the true method of treating disease. Hippocrates, I confess, has heretofore shown the path, but as he was the first to enter it, he was not able to go as far as he wished...He has opened the path, but has left it for a successor to enlarge and make plain." With such words as these from no less than a great ancient teacher, philosopher and physician, what other source of knowledge could a modern medieval person want?
Galen was born at Pesgamos in A.D. 130 during the reign of Hadrian, (famous for the wall in England). He studied Philosophy and Medicine all over the Roman Empire. He was 35 when he became physician to Emperor Marcus Aurelius. He also attended Emperors L. Verus and Septimius Severus. He died at his home of Pergamos around the year 200 A.D.
For all of his claims of being the successor of Hippocrates, Galen's works could scarcely be more different from the ancient teacher's. Where Hippocrates used observation and straightforward deduction, Galen emphasized his theories and the complexities he saw in his patients. In fact, Galen's methods were the antithesis of modern science. He was a good observer but he felt individual facts were umimportant and experience of little value unless connected to the principles he layed dowm as the basis of medicine. In other words, when observation conflicted with theory, ignore the observation!
Galen believed anatomy was essential for a docter. His writings show that he was a master of dissection. He probably did not dissect humans in Rome but did write about dissections of animals.
Although he did make some valuable original contributions to medicine, unfortunately Galen followed Hippocrates closely on his theories of the "humors" and even expanded them. He divided things not only into Earth, Air, Fire, and Water but added Dry and Moist, Spirits and Solids as well as Humors, and 8 temperaments between health and disease. He used these classifications for diagnosis, treatment, and medications. He had long lists of medications for diseases, even though he did not always trust them, and thus he is often considered the father of pharmacy. His humor theories also gave rise to odd theories on physiology.
The basic principle of life according to Galen was a spirit(pneuma) drawn from the general "world-spirit" in the act of breating. It entered the body through the trachea (windpipe) into the lungs and body through "arteria venalis" (pulmonary veins) to the left ventricle of the heart where it mixed with the blood. Blood was made constantly in the liver from foodstuffs and given pneuma of "the natural spirit". This gave the blood the power of growth and nutrition. This blood went to the body through the venous system. Some of it went across minute pores in the septum (i.e. the tissue between the sides of the heart) to get into the right part of the heart. Here it mixed with air and got another pneuma, "the vital sprirt". This went out of the arteries and gave the body activity. If it got to the brain, it got the noblest pneuma, "the animal spirit". This passes down the hollow nerves to initiate motion and sensation...
One last important thing we should mention about Galen is that he was a monotheist (he believed in one God). He did not appear to be a Christian or a Jew, but his writing had a lot in common with their beliefs. This made him a desirable teacher for the Christian leaders to come. When intellectual pursuit was being swallowed up in chaos at the end of the 2nd century A.D., Galen was viewed as a learned authority. Thus were the works, ideas, and follies of one man turned into the sole basis of medical knowledge for the next 14 centuries.
From the 2nd and the 4th centuries A.D., Roman territory declined and finally failed altogether. During this time of hunger, pestilence and war, there were few places scholars could go and feel safe. There was also a need for a place where the sick and wounded could go to seek solace. The one institution left that had the power to offer and assure asylum to these people was the Church of Rome.
Literary medicine found a haven in the churches and cloisters. Here information survived and records could be kept. Unfortunately, the monks were known as "practical men". They felt that natural law governed all of a man's life. Therefore, why should they worry about medical theories? They instead worried about practical matters of healing and tending. What worked was simply repeated. This put an end to medical learning and experimentation. It also opened the door for false treatments like charms and amulets. Once one "worked", it was used thereafter. And with all the decay of intellect around them, they of course looked to the greatest teachers of the past for any instruction they needed. Thus Galen's ideas on medicine became the foundation of medical knowledge.
There was another reason why the medical practices of the Dark Ages were centered in the monasteries. They were where the hospitals were. During the Dark Ages, lists of medical herbs were kept by the monks in the monastery. Persons needing medical help would go to these monks. St. Benedict (born 480 A.D.) encouraged monastic medicine at the hospice he founded at Montecassino. Cassiodorus (490-585?) encouraged monks in his monasteries to study medicine. He encouraged the teaching of herbs and medication but also fostered the bonds of Christian thought to its Greeco-Roman predecessor. He reemphasized the study of Hippocrates, Galen, and others. This seed of learning grew well over the next several centuries, Montecassino continued to foster medical education and grew to be renowned for its medical advances. This enlightenment set the stage for futher advancement as the early middle Ages dawned upon the world.
Before we can leave a discussion of medicine of the Dark Ages, we must stop and take a look at the medicine that prevailed in some areas before Rome and again after Rome in these areas that were not controlled by the Catholic Church. Instead of looking at each culture, we will look at a Pre-Rome representative: that of the primitive Germans.
Before the Roman conquests, the medicine of the Germans was mainly mystical or domestic. Demons were expelled from the body and sacrifices were given to appease the gods. According to Arturo Castiglioni, MD in A History of Medicine, the medicine man Kedfinger (a lachner) would touch the patient with a finger dipped in the blood of the victim to effect cures. Magic runes, stones, and herbs collected on special days along with spells were the mainstay of medical care.
Women had a special place in Pre-Roman Germanic medicinel Tacitus wrote of the ancient Germans, "Ad Matres, ad coniuges vulnera ferunt, nec illae numerare et exigere plagus parent (they take their injuries to their mothers and wives, who do not fear to examine and treat their wounds)." Some groups of women healers were reported to have supernatural powers.
After the fall of the Roman Empire, some areas that were not under the control of the Christian Church returned to the more primitive forms of medicine. The Gallo-Celtic peoples used this system until the monks christianized all of Europe and brought with them Roman-style medicine. Although mysticism remained, there was more reliance on herbalism and empirical medicine tham before. During the Dark Ages however, men completely controlled the practice of medicine. The office of healer was considered holy and reserved for the caste of Druids. They controlled medicine as well as science and religion for their people until the Benedictines and other monks changed them all forever.
After the long period of unenlightenment that was the Dark Ages, we at last find a small ray of learning dawning. The source of this light was the Carolingian Empire and Charlemagne. The Benedictines founded the cathedral schools of Charlemagne and he expanded their use. In 805 he ordained that medicine, under the name of physics, should be introduced into regular teaching programs.
One of the great schools to arise at this time was at Salerno, Italy. A hospital was founded there by Benedictines in the 7th century. Duing the time of Charlemagne, there was already a school arising which (among other things) taught medicine.
There were three new things that could be found at this school. First, lay medicine was being taught. Second, there was a cultural blending at the school. The best ideas and work of West Europe, the Greeks, the Jews, the Arabs, and the Ancients all came together in one place and were taught to all students. Lastly, we see the introduction of lay teachers. These men were physicians of all faiths who helped divorce medicine from magic and astronomy.
In the second half of the llth century, the school got another cultural and intellectual infusion. Constantinius of Af joined the school as the secretary of Robert Guiscard, Duke of Salerno. He had a passion for literature and oriental languages. He translated hundreds of works from ancient and foreign cultures that added to the schools fund of knowledge. The lay character of the school was also maintained. This was evidenced by the fact that women were admitted to lectures and professors were allowed to marry.
Another innovation of the school was that the faculty worked together in the teaching of their students as opposed to one master instructing one student. The complete faculty put out a very important work probably somewhere near the beginning of the 12th century. It was dedicated to "the King of England"-really probably Robert, Duke of Normandy, oldest son of Willian the Conqueror. Below is part of one of one of the 300 versions of the poem.
Thus it is simple medical advice, easy to remember, which all manner of people could and did commit to memory.
Moving toward 1200, the school at Salerno enjoyed greater and greater recognition throughout Europe. Another factor that helped this development was that at this time the clergy was being removed from medicine. As the practice of medicine became more widespread, it took the monks further from their Holy duties. Thus in 1130, the Church council of Clermont and the Council of the Lateran in 1139 forbade Monks and regular Clerics from practicing medicine. Finally, Pope Honorius III forbade even secular ecclesiastics to practice medicine sometime between 1216 and 1227, although they did keep control of many hospitals. So the teaching and practice of medicine fell completely into lay hands and this further enhanced the lay school of Salerno.
It is appropriate here to look at a medieval invention--the hospital. Just as there was a need for someone to record and keep the medical knowledge of the past, there was also a need for a place where the sick could go and have all the things in one place to get better. Both of these needs were filled by the Church.
It is recorded that the monastery of St. Gall in 820 had a medical herb garden, rooms for 6 sick people, a pharmacy, and special lodging for a physician. This is probably our first example in Western Europe of a hospital. The Benedictine monasteries quickly expanded the trend and soon many monasteries in Europe had attached hospitals.
During the 12th and 13th centuries, many large hospitals were made including several Great London Hospitals. These were mostly under the control of the Church but as time went on, some lay institutions cropped up as well. Also during the 12th and 13th centuries, orders of knighthood came about to care for the sick. The Knights of St. John came about during the crusades. They established their first hospital in Jerusalem and later founded one in Rhodes in 1311.
The hospitals of the later Middle Ages were grand affairs which were specifically built to be hospitals. The Hotel-Dieu in Paris had regular nurses (nuns), only 2 people per bed, good ventilation (for the time), and good waste disposal. This was the epitome of the medieval hospital indeed!
The 13th and 14th centuries were times of great growth and development in medicine. Medical teaching had progressed to the point where university degrees were required to practice medicine. In 1140, Roger, King of Sicily enforced a law prohibiting from the practice of medicine anyone who had not graduated "in order that the king's subjects should not incur dangers through the inexperience of their physician." All through the 13th century, this trend was continued and strengthened. This was also the time of the birth of the great universities. The two greatest universities with medical schools could be found at Bologna and Montpellier. These schools added greatly to medical acvancement. We know that htere was a medical faculty at Bologna as early as 1156. Early on, the school was mainly scholastic--reading and repeating the works of the ancients, without any experimentation at all. There were two men from the school at Bologna who greatly contributed to medicine at this time.
William of Saliceto (1210-1280) was instrumental in setting up a school of surgery. He himself probably dissected human cadavers. He recommended the use of the knife instead of the cautery in surgery and taught that pus in a wound was a bad thing, not a good thing. He sutured severed nerves back together in sugery. He also tried to bring the disciplines of surgery and medicine closer together.
Theodoric, Bishop of Cervia advocated the use of wine to clean wounds and suggested that the noxious compounds commonly used only impeded healing. He also wrote of narcotics such as opium, mandragora, and others being soaked into sponges. These were held over the patients' noses to induce a "deep sleep" during surgery. He was also instrumental in getting wider acceptance of dissection.
The school at Montpellier in France also contributed greatly to medicine. Dissection was practiced during the 14th century. Spectacles for the eyes were first documented by Bernard de Gordon at the end of the 13th century. This was a time of advancement in science. The art of trepanning the skull was more carefully studied and used with better precision. Herbalism was on the increase as well as cleanliness in general. There was to come one thing however, one devastating catastrophe, that would shake man to his core and reawaken the need for science.
In October 1347, a Genoese trading ship put into the harbor of Messina in Sicily with only ten men aboard. This was the beginning of an epidemic so appalling and destructive that it completely changed the social structure of Europe and left a permanent mark on human memory. The deadly cargo the ship carried from the East was a new disease, Yersinia pestis, The Plague. It is impossible to include in this paper the full scope of that event, so it will only contain the highlights. Perhaps we will have another article later on.
The diseased sailors showed strange black swellings the size of an egg in the armpits and groin. The swellings oozed blood and pus and were followed by spreading boils and black blotches all over the skin. The victem died five days later in pain. As the disease spread, another form with continuous fever and spitting blood appeared. These victems died within three days. With both types, anything which issued from the body smelled foul. Despair was the disease's companion and before the end "death is seen seated on the face." This disease spread with terrifying speed and could kill people within hours.
Within two years, the Plague ("pestilence" or "Great Death" as it was called at the time) had reached almost all of Europe. Modern demographers think Froissart was correct when he said "a third of the world died." In some places, complete populations were destroyed. In Europe at the time, a third of the population would mean some twenty million people. This is what was written at the time of the Plague:
The doctors were not immune to the dreaded disease. Of the twenty-four physicians in Venice, twenty were said to lose their lives. At Montpellier, Simon de Covino reported that although there were many doctors there, "hardly one of them escaped." We can take heart in some of the human caring that was present. The nuns at the Hotel-Dieu stayed with the sick until the staff was completely changed several times.
The doctors thought a person's gaze or the stench of the disease could transmit it, and so they covered themselves with thick clothing and held a cloth to their noses. Some wore elaborate masks shaped like birds' heads which had holders for burning incense in the beads.
One thing that should be addressed in any comprehensive review of medicine is the lasting social effects of the Plague. Severe persecutions of the Jews followed the plague, as people were always looking for someone to blame. Peasants found that for once there was not enough human labor and banded together for higher wages and even their freedom. They began to understand that a human life might be worth something intrinsically. In short, the foundation of modern thinking in many areas was laid at this time.
Since this was a new disease, there were no writings "of the ancients" they could turn to in order to heal the disease. The doctors of the time had to do something that had not been done for almost 1200 years. They had to make their own observations and do their own experiments. This allowed future doctors the freedom to think for themselves and question the ancients. Thus was some of the foundation laid for the Renaissance.
Knowledge and learning spread far and wide during the 14th century, but the work done then was only a prelude to the amazing advances to come. The use of guns became more widespread in battle, therefore the art of surgery also advanced. Wounds were treated with warm, not boiling oil. Amputations were closed with a skin flap instead of being cauterized. Plastic surgery was also founded in the 16th century!
Another great advance was printing. The end of the 15th century saw a great increase in medical literature. This is often known as the time of the great herbals and herbalism was on the increase. Hospitals were also on the increase and cities vied with each other to have the best hospitals.
Ambroise Pare (1510-1590) was one of the great surgeons of the Renaissance. He found that a mixture of eggs, oil of roses and turpentine allowed wounds to heal better than scalding oil. His contemporaries discovered the tourniquet and found that ligated arteries did better than cauterized ones.
The list of achievements goes on and on. To understand a last great factor in the growth of medicine can best be shown in one of its greatest proponents. The factor is intellectual growth and freedom, and the man is Andreas Vesalius.
Andreas Vesalius was a native of Brussels and was born into a medical family. He was trained in Greek and Latin but also learned Hebrew and Arabic so as to extend his potential for learning. In 1537, he was appointed professor of Surgery and Anatomy at Padua. It was during his three years at Padua that he produced his greatest works.
In June 1543, he published his De Human: Corporis Fabrica. In it, he not only wrote that Galen could no longer be regarded as the final authority, but described his own extensive studies in anatomy. He laid the ground work for the refutation of Galen. He also helped make anatomy not only acceptable but required as a course of study for medical students. It was Vesalius who pointed the way to the Renaissance and the future.
Thus goes the history of medicine in the Middle Ages. We see the advanced stage of work in Greece and Rome, which falls into the abyss of ignorance and superstition of the Dark Ages. Then follows the slow reemergence of knowledge and understanding. Such was the history of medicine as it is the history of man.