Medieval Medicine

There are records of other women professors of Salerno, though none of them as famous as Trotula. A lady of the name of Mercuriade is said to have written “On Crises in Pestilent Fever,” and as she occupied herself with surgery as well as medicine, there is also a work on “The Cure of Wounds.” Rebecca Guarna, who belonged to the old Salernitan family of that name, a member of which in the twelfth century was Romuald, priest, physician, and historian, wrote “On Fevers,” “On the Urine,” and “On the Embryo.” Abella acquired a great reputation with her work “On Black Bile,” and curiously enough on “The Nature of Seminal Fluid.” From these books it is clear that, while as professors they had charge of the department of women’s diseases, they studied all branches of medicine. There are a number of licences preserved in the Archives of Naples in which women are accorded the privilege of practising medicine, and apparently these licences were without limitation as to the scope of practice. The preamble of the licence, however, suggests the eminent suitability of women treating women’s diseases. It ran as follows:

“Since, then, the law permits women to exercise the profession of physicians, and since, besides, due regard being had to purity of morals, women are better suited for the treatment of women’s diseases, after having received the oath of fidelity, we permit,” etc.

The story of medical education for women with the free opportunity for practice, and above all the recognition accorded by making them professors at the University of Salerno, will seem all the more surprising to those who recall that the Benedictines largely influenced the foundation at Salerno, and were important factors in its subsequent growth and management. Ordinarily it would be presumed that monastic influence would be distinctly against permitting women to secure such opportunities for education, and, above all, encouraging their occupation with medical practice. As a matter of fact, it seems indeed to have been monastic influence which secured this special development. The Benedictines were already habituated to the idea that women were quite capable, if given the opportunity, of taking advantage of the highest education; and besides, they were accustomed to see them occupied, and successfully, with the care of the ailing. When St. Benedict established the monks of the West in retreats, where the men of the earlier Middle Ages could secure, in the midst of troubled times and with men in the cities utterly neglectful of intellectual interests, a refuge from the disturbed life around them, and an opportunity for intellectual development, his sister Scholastica afforded similar opportunities for such women as felt that they were called rather to the intellectual and spiritual life than to the taking up of the burden of domestic duties and a wife’s labours.

In these Benedictine convents for women, as they spread throughout Italy—and afterwards throughout Germany, and France, and England, though the fact is often ignored—the intellectual life was pursued as faithfully as the spiritual. Besides, there gathered around the convent gates as around the monasteries the farmers who worked their estates, and who found it so good “to live under the crozier,” as the rule of the Abbot or Abbess was called, and who always suffered severely whenever, by confiscation or war or like disturbances, the monastic lands passed into the hands of laymen. For their own large numbers as well as for their peasantry, and for the travellers who stayed in their guest-houses, the nuns had to provide medical attendance; and the infirmarians of the convents, situated as they were so often far from cities or towns, acquired considerable medical knowledge and came to apply it with excellent success. The traditions were gathered from many quarters, and passed on for centuries from one house to another; and they gathered simples and treated the ordinary ailments, and nursed the ailing into moods of greater courage and states of mind that predisposed to recovery.

Probably the most important book on medicine that we have from the twelfth century is written by a Benedictine Abbess, since known as St. Hildegarde. She was born of noble parents at Boeckelheim in the county of Sponheim, about the end of the eleventh century. She was educated at the Benedictine cloister of Disibodenberg, and when her education was finished she entered the house as a religious, and at the age of about fifty she became abbess. Her writings, reputation for sanctity, and her wise rule, eminently sympathetic as she was, attracted so many new members to the community that the convent became overcrowded. Accordingly, with eighteen of her nuns, Hildegarde withdrew to a new convent at Rupertsburg, which English and American travellers will doubtless recall because it is not far from Bingen on the Rhine, made famous in the later time by Mrs. Hemans’s poem. Here she came to be a sort of centre for the intellectual life of her period. According to traditions, some of which are dubious, she was in active correspondence with nearly every important personage of her generation. She was an intimate friend of St. Bernard of Clairvaux, who was himself perhaps the most influential man of Europe in this century. Her correspondence was enormous, and she was consulted from all sides because her advice on difficult problems of any and every kind was considered so valuable.

In spite of all this time-taking correspondence she found leisure to write a series of books, most of them on mystical subjects, but two of them, strange as it may seem, on medicine. The first is called “Liber Simplicis Medicinæ,” and the second “Liber Compositæ Medicinæ.” These books were written as a contribution of her views with regard to the medical knowledge of her time, but were evidently due, partly at least, to the Benedictine traditions of interest in medicine. Dr. Melanie Lipinska in her “Histoire des Femmes Médicins,” a thesis presented for the doctorate in medicine at the University of Paris in 1900, which was subsequently awarded a special prize by the French Academy, reviews Hildegarde’s work critically from the medical standpoint. She does not hesitate to declare the Abbess Hildegarde the most important medical writer of her time. Reuss, the editor of the works of Hildegarde as they are published in Migne’s “Patrologia,” the immense French edition of all the important works of the Fathers, Doctors, and Saints of the Church, says:

“Among all the saintly religious who have practised medicine or written about it in the Middle Ages, the most important is without any doubt St. Hildegarde....” With regard to her book he says: “All those who wish to write the history of the medical and natural sciences must read this work, in which this religious woman, evidently well grounded in all that was known at that time in the secrets of nature, discusses and examines carefully all the knowledge of the time.” He adds: “It is certain that St. Hildegarde knew many things that were unknown to the physicians of her time.”

Some of Hildegarde’s expressions are startling enough because they indicate discussion of, and attempts to elucidate, problems which many people of the modern time are likely to think occurred only to the last few generations. For instance, in talking about the stars and describing their course through the firmament, she makes use of a comparison that seems strangely ahead of her time. She says: “Just as the blood moves in the veins, causing them to vibrate and pulsate, so the stars move in the firmament, and send out sparks as it were of light, like the vibrations of the veins.” This is, of course, not an anticipation of the discovery of the circulation of the blood, but it shows how close were men’s ideas to some such thought five centuries before Harvey’s discovery. For Hildegarde the brain was the regulator of all the vital qualities, the centre of life. She connects the nerves in their passage from the brain and the spinal cord through the body with manifestations of life. She has a series of chapters with regard to psychology, normal and morbid. She talks about frenzy, insanity, despair, dread, obsession, anger, idiocy, and innocency. She says very strongly in one place that “when headache and migraine and vertigo attack a patient simultaneously, they render a man foolish and upset his reason. This makes many people think that he is possessed of a demon, but that is not true.” These are the exact words of the saint as quoted in Mlle. Lipinska’s thesis.

With this story of St. Hildegarde in mind, and the recall of other educational developments among the Benedictine nuns, it is easy to understand the developments that took place at Salerno, where monastic influence was so prominent. Just as the medical, and above all the surgical, traditions of Salerno found their way to Bologna at the beginning of the thirteenth century, so also did the regulations regarding standards in medical education, and with them medical education for women. There are definite historical documents which show that women not only studied but taught in the medical department of Bologna. The name of one of them at least is very well known. She was Alessandra Giliani, and, strange as it might appear, was one of the prosectors in anatomy of Mondino, the founder of teaching by human dissection. According to the “Cronaca Persicetana,” quoted by Medici in his “History of the Anatomical School at Bologna”:

“She became most valuable to Mondino because she would cleanse most skilfully the smallest vein, the arteries, all ramifications of the vessels, without lacerating or dividing them, and to prepare them for demonstration she would fill them with various coloured liquids, which, after having been driven into the vessels, would harden without destroying the vessels. Again, she would paint these same vessels to their minute branches so perfectly, and colour them so naturally, that, added to the wonderful explanations and teachings of the master, they brought him great fame and credit.”

This passage with its description, as coming from a woman, of a very early anticipation of our most modern anatomical technique—injection, hardening, and colouring, so as to imitate nature for the making of anatomical preparations, for class and demonstration purposes—is all the more interesting because the next great improvement in anatomical teaching, the use of wax models of dissected specimens coloured to imitate nature, came also from a woman, Madame Manzolini, also of Bologna. Feminine instinct aroused women to use their inventive ability to do away with the necessity for always recurring to the deterrent material of fresh dissections, and yet securing such preparations as would make teaching not less but more effective.

Some doubt has been thrown on certain details of the story of Alessandra Giliani, but the memorial tablet erected at the time of her death in the Hospital Church of Santa Maria de Mareto in Florence gives all the important facts, and tells the story of the grief of her fiancé, who was himself Mondino’s other assistant. Like her, he died young also, when there were high hopes of his ability, and there is more than the suspicion that these two untimely deaths may have been due to dissecting wound infections. She died “consumed by her labours,” so that it may have been phthisis; but he was taken by “a swift and lamentable death.”

Nicaise, in the Introduction to his edition of Guy de Chauliac’s “Grande Chirurgie” (Paris, 1893), has a brief review of the history of women in medicine, with special reference to France. He supplies practically all the information available in very short compass, as well as the references where more details can be obtained.

“Women continued to practise medicine in Italy for centuries, and the names of some who attained great renown have been preserved for us. Their works are still quoted from in the fifteenth century.

“There was none of them in France who became distinguished, but women could practise medicine in certain towns at least on condition of passing an examination before regularly appointed masters. An edict of 1311, at the same time that it interdicts unauthorized women from practising surgery, recognizes their rights to practise the art if they have undergone an examination before the regularly appointed master surgeons of the corporation of Paris. An edict of King John, April, 1352, contains the same expressions as the previous edict. Du Bouley, in his ‘History of the University of Paris’ gives another edict by the same king, also published in the year 1352, as a result of the complaints of the faculties at Paris, in which there is also question of women physicians. This responded to a petition: ‘Having heard the petition of the Dean and Masters of the Faculty of Medicine at the University of Paris, who declare that there are very many of both sexes, some of the women with legal title to practise and some of them merely old pretenders to a knowledge of medicine, who come to Paris in order to practise, be it enacted,’ etc. (The edict then proceeds to repeat the terms of previous legislation in this matter.)

“Guy de Chauliac speaks also of women who practised surgery. They formed the fifth and last class of operators in his time. He complains that they are accustomed to too great an extent to give over patients suffering from all kinds of maladies to the will of Heaven, founding their practice on the maxim, ‘The Lord has given as he has pleased; the Lord will take away when he pleases; may the name of the Lord be blessed.’

“In the sixteenth century, according to Pasquier, the practice of medicine by women almost entirely disappeared. The number of women physicians becomes more and more rare in the following centuries, just in proportion as we approach our own time. Pasquier says that we find a certain number of them anxious for knowledge, and with a special penchant for the study of the natural sciences and even of medicine, but very few of them take up practice.”

There seems, however, to have been not nearly so much freedom or so much encouragement for women in medicine in France as in Italy. Indeed, in the whole matter of education for women, medieval France has but little to record compared to Italy’s significant chapter in the history of feminine education. One reason for this was doubtless the Hélöise-Abélard incident early in the history of the University of Paris. This seems to have discouraged efforts in the direction of the securing of the higher education for women in most of the Western Universities. Oxford was a daughter university of Paris, and Cambridge of Oxford, and they and all the other universities of the West were more deeply influenced in their customs and organization by Paris than by Italy, and as a consequence we hear little of feminine education in the West generally. One result of this has been the existence of a feeling that, since women had very few opportunities for the higher education in Western Europe, they must have had them nowhere else. This presumption forms the basis of not a little misunderstanding of the Middle Ages in our time. It often takes but a little incident to set the current of history in a very different direction from that in which it might have gone, and this seems to have been the case as regards the higher education for women in France and Spain and England.

CHAPTER X

MEDIEVAL HOSPITALS

Our recent experience makes it easy to understand that such magnificent advance in surgery as has been described in the preceding chapters would have been quite impossible unless there were excellent hospitals in the medieval period. Good surgery demands good hospitals, and indeed inevitably creates them. Whenever hospitals are in a state of neglect, surgery is hopeless. We have, however, abundant evidence of the existence of fine hospitals in the Middle Ages, quite apart from this assumption of them, because of the surprising surgery of the period. Historical traditions from the earlier as well as the later medieval times demonstrate a magnificent development of hospital organization. While there had been military hospitals and a few civic institutions for the care of citizens in Roman times, and some hospital traditions in the East and in connection with the temples in Egypt, hospital organization as we know it is Christian in origin; and particularly the erection of institutions for the care of the ailing poor came to be looked upon very early as a special duty of Christians. Even the Roman Emperor, Julian the Apostate, declared that the old Olympian religion would inevitably lose its hold on the people, unless somehow it could show such care for others in need as the Christians exhibited wherever they obtained a foothold. It was not, however, until nearly the beginning of the Middle Ages that the Christians were in sufficient numbers in the cities, and were free enough from interference by government, to take up seriously the problem of public hospital organization. The rapidity of the development, once external obstacles were removed, shows clearly how close to the heart of Christianity was the subject of care for the ailing poor. St. Basil’s magnificent foundation at Cæsarea in Cappadocia, called the Basilias, which took on the dimensions of a city (termed Newtown) with regular streets, buildings for different classes of patients, dwellings for physicians and nurses and for the convalescent, and apparently even workshops and industrial schools for the care and instruction of foundlings and of children that had been under the care of the monastery, as well as for what we would now call reconstruction work, shows how far hospital organization, even in the latter part of the fourth century, had developed.

About the year 400 Fabiola at Rome, according to St. Jerome, “established a Nosocomium to gather in the sick from the streets, and to nurse the wretched sufferers wasted from poverty and disease.” A little later Pammachius, a Roman Senator, founded a Xenodochium for the care of strangers which St. Jerome praises in one of his letters. At the end of the fifth century Pope Symmachus built hospitals in connection with the three most important churches of Rome, St. Peter’s, St. Paul’s, and St. Lawrence’s. During the Pontificate of Vigilius, Belisarius founded a Xenodochium in the Via Lata at Rome, shortly after the middle of the sixth century. Christian hospitals were early established in the cities of France; and not long after the conversion of England, in that country.

In connection with these hospitals, it is rather easy to understand the fine development of surgery by early Christian physicians which we have traced. The later medieval period of hospital building, however, is of particular interest in the history of medicine, because we have such details of it as show its excellent adaptation to medical and surgical needs. According to Virchow, in his article on the History of German Hospitals, which is to be found in the second volume of his collected “Essays on Public Medicine and the History of Epidemics,”[14 - “Gesammelte Abhandlungen aus dem Gebiete der Oeffentliche Medizin,” Hirschwald, Berlin, 1877.] the story of the foundation of these hospitals of the Middle Ages, even those of Germany, centres around the name of one man, Pope Innocent III. Virchow was not at all a papistically inclined writer, so that his tribute to the great Pope who solved so finely the medico-social problems of his time undoubtedly represents a merited recognition of a great social development in history.

“The beginning of the history of all these German hospitals is connected with the name of that Pope who made the boldest and farthest-reaching attempt to gather the sum of human interests into the organization of the Catholic Church. The hospitals of the Holy Ghost were one of the many means by which Innocent III. thought to hold humanity to the Holy See. And surely it was one of the most effective. Was it not calculated to create the most profound impression to see how the mighty Pope, who humbled emperors and deposed kings, who was the unrelenting adversary of the Albigenses, turned his eyes sympathetically upon the poor and the sick, sought the helpless and the neglected upon the streets, and saved the illegitimate children from death in the waters! There is something at once conciliating and fascinating in the fact that, at the very time when the fourth crusade was inaugurated through his influence, the thought of founding a great organization of an essentially humane character, which was eventually to extend throughout all Christendom, was also taking form in his soul; and that in the same year (1204) in which the new Latin Empire was founded in Constantinople, the newly erected hospital of the Holy Spirit, by the old bridge on the other side of the Tiber, was blessed and dedicated as the future centre of this organization.”

According to tradition, just about the beginning of the thirteenth century Pope Innocent resolved to build a hospital in Rome. On inquiry, he found that probably the best man to put in charge of hospital organization was Guy or Guido of Montpellier, of the Brothers of the Holy Ghost, who had founded a hospital at Montpellier which became famous throughout Europe for its thorough organization. Accordingly he summoned Guido to Rome, and gave into his hands the organization of the new hospital, which was erected on the other side of Tiber in the Borgo not far from St. Peter’s. Indeed, Santo Spirito Hospital, as it came to be called, was probably the direct successor of the hospital which Pope Symmachus (488-514) had had built in connection with St. Peter’s not long after the beginning of the Middle Ages. It is easy to understand that at the time when magnificent municipal structures, cathedrals, town halls, abbeys, and educational institutions of various kinds were being erected, with exemplary devotion to art and use, the Hospital of Santo Spirito under the special patronage of the Pope was not unworthy of its time.[15 - See Walsh, “The Thirteenth, Greatest of Centuries,” New York, seventh edition, 1914.] We know very little, however, about the actual structure.

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THIRTEENTH-CENTURY HOSPITAL INTERIOR (TONERRE)

From “The Thirteenth: Greatest of Centuries,” by J. J. Walsh

Then, as now, Bishops made regular visits at intervals ad limina—that is, to the Pope as Chief Bishop of the Church; and according to tradition Pope Innocent called their attention particularly to this hospital of Santo Spirito, one of his favourite institutions, and suggested that every diocese in Christendom ought to have such a refuge for the ailing poor. The consequence was the erection of hospitals everywhere throughout Europe. Virchow has told the story of these hospital foundations of the Holy Ghost, as they were called, and makes it very clear that probably every town of 5,000 inhabitants everywhere throughout Europe at this time had a hospital. The traditions with regard to France are quite as complete as those that concern Germany and the great hospitals of London—St. Thomas’s; St. Bartholomew’s, which had been a priory with a house for the care of the poor, but was now turned into a hospital; Bethlehem, afterwards Bedlam; Bridewell, and Christ’s Hospital, the first of which afterwards became a prison, while Christ’s Hospital, though retaining its name, became a school. The Five Royal Hospitals, as they were called, were either founded, or received a great stimulus and thorough reorganization, during the thirteenth century.

It would be easy to suppose these hospitals were rather rude structures, inexpertly built, poorly arranged, and above all badly lighted and ventilated. They might be expected to furnish protection from the elements for the poor, but scarcely more, and probably became in the course of time hotbeds of infection because of their lack of air and uncleanness. As a matter of fact, they were almost exactly the opposite of any such supposition. Those in the larger towns at least were model hospitals in many ways, and ever so much better than many hospital structures erected in post-medieval centuries. Indeed, the ordinary impression as to the medieval hospitals, and their lack of suitability to their purpose, would apply perfectly to the hospitals of the latter half of the eighteenth and the early nineteenth centuries. It is because our generation still has the memory of these hospitals of the past generation, and assumes that if these were so bad, the hospitals of an earlier time must have been worse and the hospitals of the medieval period must have been intolerable, that the derogatory tradition with regard to medieval hospitals and many other medical subjects maintained itself until the coming of real information with regard to them.

The ecclesiastical architecture of the later Middle Ages was not only beautiful, but it was eminently suitable for its purpose, and above all provided light and air. The churches, the town halls, the monasteries and abbeys, were models in their kind, and it would have been quite surprising if the hospitals alone had been unworthy products of that great architectural period. As abundant remains serve to show even to the present time, they were not. The hospitals built in the thirteenth century particularly usually were of one story, had high ceilings with large windows, often were built near the water in order that there might be abundance of water for cleansing purposes, and also so that the sewage of the hospital might be carried off, had tiled floors that facilitated thorough cleansing, and many other provisions that the architects of our time are reintroducing into hospital construction. They were a complete contrast to the barrack-like hospitals with small windows, narrow corridors, cell-like rooms, which were built even two generations ago, and which represented the lowest period in hospital building for seven centuries.

Viollet le Duc, in his “Dictionary of Architecture,” has given a picture of the interior of one of these medieval hospitals, that of Tonnerre in France, erected by Marguerite of Bourgogne, the sister of St. Louis, in 1293, which we reproduce here. Mr. Arthur Dillon, discussing this hospital from the standpoint of an architect, says:

“It was an admirable hospital in every way, and it is doubtful if we to-day surpass it. It was isolated, the ward was separated from the other buildings, it had the advantages we so often lose of being but one story high, and more space was given to each patient than we can now afford.

“The ventilation by the great windows and ventilators in the ceiling was excellent; it was cheerfully lighted, and the arrangement of the gallery shielded the patients from dazzling light and from draughts from the windows, and afforded an easy means of supervision; while the division by the roofless, low partitions isolated the sick, and obviated the depression that comes from the sight of others in pain.

“It was, moreover, in great contrast to the cheerless white wards of to-day. The vaulted ceiling was very beautiful; the woodwork was richly carved, and the great windows over the altars were filled with coloured glass. Altogether, it was one of the best examples of the best period of Gothic architecture.”

The hospital ward itself was 55 feet wide and 270 feet long and had a high arched ceiling of wood. The Princess herself lived in a separate building, connected with the hospital by a covered passage. The kitchen and storehouse for provisions were also in separate buildings. The whole hospital plant was placed between the branches of a small stream conducted around it, which served to temper the atmosphere, and was a source of water supply at one end of the grounds and helped in the disposal of sewage from the other end.

A hospital of the Holy Ghost which may be taken as the type of such structures is still standing at Lübeck in Germany, and was, like the hospital at Tonnerre, also built during the thirteenth century. It was erected as the result of the movement initiated by Pope Innocent’s foundation of the Santo Spirito at Rome. The picture of this, in my “Thirteenth Century,” will serve to show what Holy Ghost hospitals in important cities at least were like. Lübeck was one of the rich Hansa towns in the thirteenth century, but there were many others of equal importance, or very nearly so, and all of these towns were rivals in the architectural adornment of their municipalities, and particularly in the erection of cathedrals, town halls, guild halls, and other buildings for the use of citizens.

The older portion of the Hospital of St. Jean at Bruges also gives an excellent idea of a later medieval hospital as it was constructed in a populous commercial town. Bruges, almost needless to say, was one of the most important cities of Europe in the fourteenth century. The Hospital of St. Jean, then, was built, like the cathedral and churches and the town hall, so as to be worthy of the city’s prestige. The older part, which is now used for a storeroom, has the characteristics of the best medieval hospitals. The ward was one story in height, the windows were large, high in the walls, and the canals that flowed around the hospital made pleasant vistas for the patient, while the gardens attached were eminently suitable for convalescents. The phases of hospital building down the centuries can be studied at St. Jean, and, strange as it may seem, the oldest portion of the hospital, that of the medieval period, provided the most light and air for the patients and the best opportunity for thorough cleansing, as well as for occupation of the patients’ minds with details of the construction that were visible from any part of the ward.

The hospitals of the Middle Ages are particularly interesting, because they represent a solution of the social problems other than merely the relief of pain and suffering, or the care of the needy who have none to care for them. They represent a ready, constantly near opportunity for the better-to-do classes to exercise charity toward those who needed it most. The hospitals were always in the busiest portions of the towns, and were often visited by the citizens, both men and women. Dr. John S. Billings, in his description of “The Johns Hopkins Hospital” (Baltimore, 1890), touched upon this spirit of the hospital movement of the Middle Ages in a very appropriate way when he said:

“When the medieval priest established in each great city of France a Hotel Dieu, a place for God’s hospitality, it was in the interest of charity as he understood it, including both the helping of the sick poor, and the affording of those who were neither sick nor poor an opportunity and a stimulus to help their fellow-men; and doubtless the cause of humanity and religion was advanced more by the effect on the givers than on the receivers.”

A rather significant historical detail with regard to medieval hospitals is the foundation of a special order to take care of the hospitals in which St. Anthony’s Fire, or what we know as erysipelas, was treated. Apparently this indicated the recognition of the contagiousness of this disease by the medieval people. Pope Honorius III. approved the foundation of an order of nurses particularly devoted to the care of patients suffering from this affection. Other religious congregations for the same works seem to have been established. We did not recognize the contagiousness of the disease until the last generation. Undoubtedly these special foundations made it possible to control many of the epidemics of erysipelas that used to make surgical care in our hospitals in the modern time such a difficult matter. Even as late as our Civil War here in America, erysipelas was the special dread of the hospital surgeon. Oliver Wendell Holmes pointed out that erysipelas might readily be carried to the parturient woman with the production of child-bed fever. It is interesting to realize, then, the attempt of the medieval period to segregate the disease.

“On the outskirts of a town, seven hundred years ago, the eye of the traveller would have been caught by a well-known landmark—a group of cottages, with an adjoining chapel, clustering round a green enclosure. At a glance he would recognize it as the lazar-house, and would prepare to throw an alms to the crippled and disfigured representative of the community.”]

Besides hospitals, a series of lazarettos—that is, of buildings for the segregation of lepers—were erected in the various countries of Europe during the medieval period. Just about the end of the Crusades it was discovered that leprosy had become very common throughout Europe. It is often said that leprosy was introduced at this time, but it had evidently been in the West for many centuries before. Gregory of Tours mentions leper hospitals as early as 560, and the disease evidently continued to progress, in spite of these special hospitals, until in the thirteenth century it became clear that strenuous efforts would have to be made to wipe out the disease. Accordingly, leproseries were erected in connection with practically every town in Europe at this time. Baas estimates that there were some 19,000 of them in Europe altogether. Virchow has listed a large number of the leper hospitals of the German cities, quite enough to show that probably no organized community was without one.

As a consequence of this widespread movement of enforced segregation, leprosy gradually died out in Europe, remaining only here and there in backward localities. The disease was probably as common during the later Middle Ages as tuberculosis is among us at the present time. The recently discovered relations between the bacterial cause of the two diseases may give rise to the question as to whether we shall succeed as well with the great social and hygienic problem that confronts our generation, of lowering the death-rate from “the great white plague,” as the medieval generations did with their chronic folk-disease, leprosy. It would be “a consummation devoutly to be wished.” We are now beginning to have as many sanatoria for tuberculosis in proportion to the population as they had of leproseries. These leproseries, or lazarettos, as they were called, were not at all the dreadful places that the imagination has been wont to picture them in recent years; on the contrary they were, as a rule, beautifully situated on a side-hill to favour drainage, consisted of a series of dwellings with a chapel in their midst surrounded by trees, and encompassed by what was altogether a park effect. Miss Clay, in “Medieval Hospitals,” has given a picture of one of them, which we reproduce, because it serves to contradict the popular false notion with regard to the bare and ugly and more or less jail-like character of these institutions.

CHAPTER XI

MEDIEVAL CARE OF THE INSANE

Quite contrary to the usual impression, rather extensive and well-managed institutions for the care of the insane came into existence during the Middle Ages, and continued to fulfil a very necessary social and medical duty. For the unspeakable neglect of the insane which is a disgrace to civilization, we must look to the centuries much nearer our own than those of the Middle Ages. Above all, the Middle Ages did not segregate the insane entirely from other ailing patients until their affections had become so chronic as to be certainly incurable, and they took the insane into ordinary hospitals to care for them at the beginning of their affection. This mode of procedure has many advantages, mainly in getting the patients out of unfavourable environments and putting them under skilled care early in their affections, so that a definite effort is being made to restore what is called the psychopathic ward in the general hospitals in our time. Only a careful study of the details of actual historical references to the medieval care of the insane will serve to contradict unfortunate traditions which have gathered around the subject entirely without justification in real history.

The traditions of medical knowledge with regard to the insane inherited by the early Middle Ages from the ancients were of the best, and the books written at this time have some interesting material on the subject. Paulus Aëgineta (Aëginetus), who wrote in the seventh century—and it must not be forgotten that already at this time some 200 years of the Middle Ages have passed—has some excellent directions with regard to the care and treatment of patients suffering from melancholia and mania. He says, in his paragraph on the cure of melancholy: “Those who are subject to melancholy from a primary affection of the brain are to be treated with frequent baths and a wholesome and humid diet, together with suitable exhilaration of mind, and without any other remedy unless, when from its long continuance, the offending humour is difficult to evacuate, in which case we must have recourse to more powerful and complicated plans of treatment.” He then gives a series of directions, some of them quite absurd to us, apparently in order to satisfy those who feel that they must keep on doing something for these cases, though evidently his own opinion is expressed in the first portion of the paragraph, and in the simple laxative treatment that he outlines. “These cases are to be purged first with dodder of thyme (epithymus) or aloes; for if a small quantity of these be taken every day it will be of the greatest service, and open the bowels gently.”

His directions as to diet for those suffering from melancholia are all in the line of limiting the consumption of materials that might possibly cause digestive disturbance, for evidently his experience had taught him that the depression was deeper whenever indigestion occurs. He says: “The diet for melancholics shall be wholesome and moderately moistening; abstaining from beef, roe’s flesh, dried lentils, cabbages, snails, thick and dark coloured wines, and in a word from whatever things engender black bile.” Mania was to be treated very nearly like melancholia, with special warnings as to the necessity for particular care of these patients. “But above all things they must be secured in bed, so that they may not be able to injure themselves or those who approach them; or swung within a wicker basket in a small couch suspended from on high.” This last suggestion would seem to be eminently practical, especially for young people who are not too heavy, and enforces the idea that the physicians of this time were thinking seriously of their problems of care for the insane and exercising their ingenuity in inventions for their benefit.

Paul of Ægina seems, then, to have thought that mania and melancholia were definitely related to each other, and to have held a similar opinion in this regard to Aretæus, who declared that melancholia was an incipient mania. Both had evidently noted that in most cases there were melancholic and maniacal stages in the same patient. These early medieval students of mental disease, then, anticipated to a rather startling extent our most recent conclusions with regard to the essential insanities. They would have been much readier to agree with Kraepelin’s term, manic-depressive insanity, than with the teaching of the hundred years before our time, which so absolutely separated these two conditions.