The Greatest Benefit to Mankind: A Medical History of Humanity

BARBARIAN INVASIONS, the collapse of the western Roman empire, and the rise of warrior fiefdoms spelt catastrophe for civilization and its amenities – including the teaching and practice of learned medicine. City life collapsed in Europe into a landscape dominated by castles and cathedrals, with literate men and women confined to monastic cloisters. The medical thread was, however, unbroken, even if it frayed and threatened to snap. Through what are known as the Dark Ages medical manuscripts were at least preserved, copied and studied within the sanctuaries provided by abbeys and cathedral schools. The medicine they kept alive was, however, but a shadow of its brilliance in Galen’s day: a basic survival kit when book-learning itself was under threat.

The revival of formal medicine took place centuries later in the backward West than in the Islamic world – not until around 1100, emerging first in Salerno in southern Italy, thirty miles south of Naples and seventy miles from the glorious Benedictine monastery of Monte Cassino. And it had to be imported and replanted.

THE WEST COMES TO LIFE AGAIN

The Salerno medical school was supposedly founded by four scholars – a Latin teacher, a Jew, an Arab and a Greek who had brought to the West the writings of Hippocrates. This legend carries a figurative truth. Sited in mid-Mediterranean and protected by the modernizing Norman dukes of Sicily, Salerno lay at a crossroads – cultural, economic and ethnic. In 1063, Alphanus (d. 1085), a Benedictine monk of Monte Cassino who had become archbishop of Salerno, travelled to Constanti nople where he became acquainted with Greek medical texts. His Premnon Physicon introduced into the Latin-speaking world a Christianized Galenism, while his writings on the humours and the pulse reflected Byzantine medicine. Together Alphanus’s works amount to a more philosophical approach to medicine than that hitherto available in the West, hellenizing it and enabling the physician to set himself above the workaday healer.

Later Salernitan teaching texts continued the latinization of Greek writings, and Salerno channelled Arabic medicine into the West, under the stimulus of Constantinus Africanus (c. 1020–87). A native of Carthage (in modern Tunisia) who became a monk of Monte Cassino, Constantine relayed texts of Arabic and Greek medicine, the most important of his translations being the Pantegni [The Whole Art] of Haly Abbas (d. 994). Many Greek texts which had been translated into Arabic were now latinized by Constantine, notably Galen’s Method of Healing, his commentaries on Hippocrates’ Aphorisms, his Regimen in Acute Diseases, Prognostic and the Art of Medicine. Constantine also made a version of Hunayn’s (Johannitius’) Medical Questions, known as the Liber Ysagogarum [Isagogue or Introduction]. By the mid-twelfth century these texts were seeping beyond Italy.

Constantinc’s translations were crucial, providing as they did the means whereby Latin Christendom gained access to the tradition of Hippocratic learning rationalized by Galen and digested by the Arabs. For the first time since the sixth century, Latin speakers could share in contemporary medical thinking. Providing a framework for medical teaching on diagnosis and therapy, the Liber Ysagogarum became a foundation text in the medical schools which sprang up in Italy and France, forming the basis of the Articella (see below).

The Liber Ysagogarum also broadened and gave greater prominence to the Galenic idea of the ‘six non-naturals’ – food and drink, environment, sleep, exercise, evacuations (including sexual) and state of mind; by regulating these, natural body balance could be preserved in the medical analogue to monastic rule. Stressing regimen, the non-naturals set the mould for medieval therapeutics, particularly in popular health books emanating from Salerno. The Regimen sanitatis salernitanum [Salernitan Regime of Health], a book of verses probably compiled in the thirteenth century and sometimes credited to Arnald of Villanova (1240–1311), supplied tips for healthy living from youth to old age, highlighting hygiene, exercise, diet and temperance. The first of the home health manuals, its enduring popularity is shown by the number of later printed editions: some 240 versions in Latin and other European languages, as well as Hebrew and Persian. And no wonder, since it was simple and even entertaining in its advocacy, alongside Galenic venesection, of Drs Quiet, Diet and Merryman.

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Salernitan translations and teachings created a new canon of medical authority known as the Articella [Little Art of Medicine], which included the Liber Ysagogarum and Hippocrates’ Aphorisms and Prognostic, supplemented by Galen’s Tegni and the Hippocratic On Regimen in Acute Diseases in a translation by Gerard of Cremona (fl. 1150–87). Rapidly becoming canonical, the Articella or Ars medicinae marked a turning point in the revival of medicine in the West. It combined translations from Greek and Arabic; it was concerned with theory, providing a basis of philosophical knowledge organized around key themes; its discussions set medicine within a wider conception of nature; and its Aristotelian orientation appealed to university scholastics. Not least, the Articella gave medicine a distinctly Galenic complexion. Pre-Salernitan compendia had included texts drawn from the Methodist as well as the Hippocratic tradition; Galen had not eclipsed all others. But the Articella texts were wholly Galenic: a proper doctor could thenceforth be defined as a man who knew his Galen.

Learned medicine continued to develop, thanks to the rise of universities (discussed below) and further access to scholarship via translation. The business of Latin translation proceeded through several stages. The first, the Salernitan, involved both Greek and Arabic texts. From the 1140s, there was a great outpouring of Latin translations from Arabic made in Muslim Spain, sometimes by way of Hebrew intermediaries. This development, which included philosophical texts, especially Aristotle, as well as medical, was led by Gerard of Cremona. Settling in Toledo, he translated an incredible quantity of material from Arabic – twenty-four works on medicine alone, including the Qanun of Avicenna, the Liber Almansorius of Rhazes (al-Razi), the last part of Albucasis’ De cirurgia, the Ars parva and other works of Galen, and the Commentary on Galen’s Art of Medicine by Haly Rodoan (Ali-ibn Ridwan). The Qanun or Canon of Medicine became the cornerstone of the medical curriculum at the University of Montpellier, remaining a textbook there until 1650! These translations created a richer terminology for learned medicine in Latin and provided Galenic medicine with a logical backbone. Medicine could now speak the language of scholasticism.

A century later there came a further burst of translations, mainly in Spain and Italy, latinizing other major works of Arabic science. These included the Continens [All-Embracing Book] of al-Razi (trans. 1282); and the Colliget [The Book of Universals] of Ibn Rushd, translated in Padua in 1283. The key figure in this drive was Arnald of Villanova. After studying medicine at Montpellier, he became a teacher and a polymath. Not only a translator of medical works, he was physician to the popes and the Aragonese royal family in Spain; later in life, he pored over theology, propounding heterodox ideas – his astrological computations predicted the world would end in 1378. As a theoretician, Arnaud aspired to rationalize Galenic medical theory with mathematical precision, by drawing on Arabic writers, notably al-Kindi and Averroës.

His Italian contemporary Pietro d’Abano (1257-c. 1315) made versions directly from Greek manuscripts he had carried back from Constantinople, including the beginning of a translation of Galen’s On the Use of the Parts of the Body. Niccolò da Reggio (fl. 1315–48) translated over fifty Galenic writings, many for the first time, including the entire text of that work. There was also translation from Latin into the vernacular, in growing demand when town life was reviving and courts and burghers were hungry for knowledge. The Surgery of John of Arderne (c. 1307–70), discussed below, exists in both Latin and English versions, and Bartholomew the Englishman’s (d. 1260) De proprietatibus rerum (1246) [On the Properties of Things] also enjoyed wide circulation in both tongues. Parts of the Articella were made available in French and English, and even in Welsh and Gaelic. For a couple of centuries, the translation movement had no less momentous consequences in Europe than in Islam, bolstering the prestige of antiquity and canonizing a Galenic medicine set in an arabized Aristotelian framework. Medical knowledge was buttressed not just by its classical heritage but by its place within the divine scheme of Christianity.

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.