Poverty always mingles myth with medicine, for myth is free and science is dear. The basic picture of medieval medicine is the mother with her little store of household remedies; old women wise in herbs and plasters and magic charms; herbalists peddling curative plants, infallible drugs, and miraculous pills; midwives ready to sever new life from old in the ridiculous ignominy of birth; quacks ready to cure or kill for a pittance; monks with a heritage of monastic medicine; nuns quietly comforting the sick with ministration or prayer; and, here and there, for those who could afford them, trained physicians practicing more or less scientific medicine. Monstrous drugs and fabulous formulas flourished; and just as certain stones held in the hand were by some believed to ward off conception, so—even in medical Salerno—some women and men ate asses’ dung to promote fertility.58
Until 1139 some members of the clergy practiced medicine, and what hospitalization could be had was usually to be found in monastic or conventual infirmaries. The monks played an honorable role in preserving the medical heritage, and led the way in the cultivation of medicinal plants; and perhaps they knew what they were doing in mingling miracle with medicine. Even nuns might be skilled in healing. Hildegarde, the mystic Abbess of Bingen, wrote a book of clinical medicine—Causae et curae (c. 1150)—and a book of Subtilitates, marred here and there with magic formulas, but rich in medical lore. The retirement of old men or women into monasteries or convents may have been motivated in part by a desire for continuous medical attendance. As lay medicine developed, and the love of gain infected monastic healing, the Church (1130, 1339, 1663) progressively forbade the public practice of medicine by the clergy; and by 1200 the ancient art was almost completely secular.
Scientific medicine survived the Dark Ages in the West chiefly through Jewish physicians, who circulated Greco-Arabic medical knowledge in Christendom; through the Byzantine culture of southern Italy; and through translations of Greek and Arabic medical treatises into Latin. Probably the School of Salerno was best situated and prepared to take advantage of these influences; Greek, Latin, Moslem, and Jewish physicians taught or studied there; and till the twelfth century it remained the leading medical institution in Latin Europe. Women studied nursing and obstetrics at Salerno;59 mulleres Salernitanae were probably midwives trained in the school. One of the most famous Salernitan products was an obstetrical treatise of the early twelfth century, entitled Trotulae curandarum aegritudinum muliebrum—Trotula on the Cure of Diseases of Women; in the generally accepted theory Trotula was a midwife of Salerno.60 Several important treatises, covering nearly all branches of medicine, have reached us from the School of Salerno. One, by Archimatheus, prescribes the proper bedside manner: the physician must always regard the patient’s condition as grave, so that a fatal end may not disgrace him, and a cure may add another marvel to his fame; he should not flirt with the patient’s wife, daughter, or maidservant; and even if no medicine is necessary he should prescribe some harmless concoction, lest the patient think the treatment not worth the fee, and lest nature should seem to have healed the patient without the physician’s aid.61
The School of Salerno gave way to the University of Naples after 1268, and little is heard of it thereafter. By that time its graduates had spread Salernitan medicine through Europe. Good schools of medicine existed in the thirteenth century at Bologna, Padua, Ferrara, Perugia, Siena, Rome, Montpellier, Paris, and Oxford. In these schools the three main medical traditions of the Middle Ages—Greek, Arabic, and Judaic—were merged and absorbed, and the entire medical heritage was reformulated to become the basis of modern medicine. Ancient methods of diagnosis by auscultation and urinalysis retained (and retain) their popularity, so that in some places the urinal became the emblem or signboard of the medical profession.62 Ancient methods of treatment by purgation and bloodletting continued, and in England the physician was a “leech.” Hot baths were a favorite prescription; patients traveled to “take the waters” of mineral springs. Diet was minutely prescribed in nearly every illness.63 But drugs abounded. Almost every element was used as a cure, from seaweed (rich in iodine), which Roger of Salerno recommended for goiter in 1180, to gold, which was imbibed to “comfort sore limbs”64—apparently our fashionable treatment for arthritis. Practically every animal organ found some therapeutic use in the medieval pharmacopeia—the horns of deer, the blood of dragons, the bile of vipers, the semen of frogs; and animal excrement was occasionally prescribed.65 The most popular of all drugs was theriacum, a weird mixture composed of some fifty-seven substances, of which the chief was the flesh of poisonous snakes. Many drugs were imported from Islam, and kept their Arabic names.
As the supply of trained physicians increased, governments began to regulate medical practice. Roger II of Sicily, probably influenced by old Moslem precedents, restricted the practice of medicine to persons licensed by the state. Frederick II (1224) required for such practice a license from the School of Salerno. To obtain it the student had to survive a three-year course in scientia logicalis—presumably meaning natural science and philosophy; he had then to study medicine at the school for five years, pass two examinations, and practice for a year under the supervision of an experienced physician.66
Every city of any importance paid physicians to treat the poor without charge.67 Some cities had a measure of socialized medicine. In Christian Spain of the thirteenth century a physician was hired by the municipality to care for a specified part of the population; he made periodically a medical examination of each person in his territory, and gave each one advice according to his findings; he treated the poor in a public hospital, and was obliged to visit every sick person three times a month; all without charge, except that for any visit above three in any month he was allowed to ask a fee. For these services the physician was exempted from taxes, and received an annual salary of twenty pounds,68 equivalent to some $4000 today.*
As licensed physicians were not numerous in thirteenth-century Christian Europe, they earned good fees, and had a high social status. Some amassed considerable fortunes; some became art collectors; several won an international reputation. Petrus Hispanus—Peter of Lisbon and Compostela—migrated to Paris and then to Siena, wrote the most popular medieval handbook of medicine (Thesaurus pauperum—Treasure of the Poor) and the best medieval discussion of psychology (De anima), became Pope John XXI in1276, and was crushed to death by a falling ceiling in 1277. The most famous Christian physician of this period was Arnold of Villanova (c. 1235–1311). Born near Valencia, he learned Arabic, Hebrew, and Greek, studied medicine at Naples, taught it or natural philosophy at Paris, Montpellier, Barcelona, Rome, and wrote a great number of works on medicine, chemistry, astrology, magic, theology, wine making, and the interpretation of dreams. Made physician to James II of Aragon, he repeatedly warned the King that unless he protected the poor against the rich he would go to hell.70 James loved him nevertheless, and sent him on many diplomatic missions. Shocked by the misery and exploitation that he saw in many countries, he became a follower of the mystic Joachim of Flora, and declared, in letters to princes and prelates, that the wickedness of the mighty and the luxury of the clergy heralded the destruction of the world. He was accused of magic and heresy, and was charged with having alchemically produced ingots of gold for King Robert of Naples. He was condemned by an ecclesiastical court, but was released from prison by Boniface VIII. He successfully treated the old Pope for kidney stones, and received from him a castle at Anagni. He warned Boniface that unless the Church should be thoroughly reformed the divine wrath would soon descend upon her; soon thereafter Boniface suffered famous indignities at Anagni, and died in despair. The Inquisition continued to pursue Arnold, but kings and popes protected him for their ailments’ sake, and he died by drowning on a mission from James II to Clement V.71
Surgery in this period fought a two-front war against the barbers on one side and general practitioners on the other. For a long time the barbers had given enemas, pulled teeth, treated wounds, and let blood. Surgeons who had received formal medical training protested against the tonsorial performance of such ministrations, but the law defended the barbers throughout the Middle Ages. In Prussia till the time of Frederick the Great it remained one of the duties of the army surgeon to shave the officers.72 Partly through this overlapping of functions, the surgeons were considered inferior to the physicians in science and society; they were looked upon as simple technicians obeying the directions of the doctor, who usually, before the thirteenth century, disdained to practice surgery himself.73 Surgeons were further discouraged by fear of imprisonment or death if their procedures failed; only the bravest undertook dangerous operations; and most surgeons, before such an enterprise, required a written guarantee that no harm would come to them in case of failure.74
Nevertheless surgery advanced more rapidly in this period than any other branch of medicine, partly because it was forced to deal with conditions rather than theories, partly through plentiful opportunity to treat the wounds of soldiers. Roger of Salerno, about 1170, published his Practica chirurgiae, the earliest surgical treatise in the Christian West; for three centuries it remained a classic text. In 1238 Frederick II ordered that a corpse should be dissected in every five-year period at Salerno;75 such dissection of cadavers was practiced regularly in Italy after 1275.76 In 1286 a Cremona physician opened a corpse to study the cause of a current pestilence; this is the first known case of a post-mortem examination. In 1266 Teodorico Borgognoni, Bishop of Cervia, began a long struggle of Italian medicine against the Arabic notion that suppuration must first be encouraged in the treatment of wounds; his discussion of aseptic treatment is a classic of medieval medicine. Guglielmo Salicetti—William of Saliceto (1210–77)—professor of medicine at Bologna, made notable improvements in his Chirurgia (1275); it associated surgical diagnosis with a knowledge of internal medicine, used careful clinical records, showed how to suture divided nerves, and advocated the knife—as allowing better healing, and leaving less scar—in preference to the cautery so popular with Moslem practitioners. In a general treatise—Summa conservationis et curationis—William ascribed chancre and bubo to intercourse with an infected courtesan, gave a classical description of dropsy as due to hardening and narrowing of the kidneys, and offered excellent advice on hygiene and diet for every age of life.
His pupils Henri de Mondeville (1260?-1320) and Guido Lanfranchi (d. 1315) brought the medical lore of Bologna to France. Like Teodorico, de Mondeville improved asepsis by advocating a return to Hippocrates’ method of maintaining simple cleanliness in a wound. Lanfranchi, exiled from Milan in 1290, went to Lyons and Paris, and wrote a Chirurgia magna which became the recognized text of surgery at the University of Paris. He laid down a principle that rescued surgery from barberism: “No one can be a good physician if he is ignorant of surgery; and no one can properly perform operations if he does not know medicine.”77 Lanfranchi was the first to use neurotomy for tetanus, and intubation of the esophagus, and gave the first surgical description of concussion of the brain. His chapter on injuries of the head is one of the peaks in the history of medicine.
Surgical sleeping draughts are mentioned by Origen (185–254) and Bishop Hilary of Poitiers (c. 353). The usual method of anesthesia in medieval Christendom was by inhaling, and probably drinking, a mixture based on mandragora (mandrake), and generally containing also opium, hemlock, and mulberry juice; mention of this “soporific sponge” occurs from the ninth century onward.78 Local anesthesia was induced by a poultice soaked in a similar solution. The patient was awakened by applying fennel juice to his nostrils. Surgical instruments had as yet made no progress since the Greeks. Obstetrics had fallen behind the practice of Soranus (C. A.D. 100) and Paul of Aegina (C. A.D. 640). Caesarean section was discussed in the literature, but apparently not practiced. Embryotomy—mutilation of the foetus for removal from the womb—was in many cases performed because the obstetrician rarely understood version. Delivery was accomplished in specially designed chairs.79
Hospitals were now advanced far beyond anything known in antiquity. The Greeks had had asklepieia, religious institutions for the treatment of the sick; the Romans had maintained hospitals for their soldiers; but it was Christian charity that gave the institution a wide development. In 369 St. Basil founded at Caesarea in Cappadocia an institution called after him the Basilias, with several buildings for patients, nurses, physicians, workshops, and schools. St. Ephraim opened a hospital at Edessa in 375; others rose throughout the Greek East, and in specialized variety. The Byzantine Greeks had nosocomia for the sick, brephotrophia for foundlings, orphanotrophia for orphans, ptochia for the poor, xenodochia for poor or infirm pilgrims, and gerontochia for the old. The first hospital in Latin Christendom was founded by Fabiola at Rome about 400. Many monasteries provided small hospitals, and several orders of monks—Hospitalers, Templars, Antonines, Alexians—and nuns arose to care for the sick. Innocent III organized at Rome in 1204 the hospital of Santo Spirito, and under his inspiration similar institutions were set up throughout Europe; Germany alone had, in the thirteenth century, over a hundred such “hospitals of the Holy Spirit.” In France the hospitals served the poor and old and the pilgrim, as well as the sick; like the monastic centers they offered hospitality. About 1260 Louis IX established at Paris an asylum, Les Quinze-vingt; originally a retreat for the blind, it became a hospital for eye diseases, and is now one of the most important medical centers in Paris. The first English hospital known to history (not necessarily the first) was established at Canterbury in 1084. Usually the service in these hospitals was provided free for those who could not pay, and (except in monastic hospitals) the attendants were nuns. The apparently cumbersome costume of these “angels and ministers of grace” took form in the thirteenth century, probably to protect them from communicable disease; hence, perhaps, the shearing of the hair and the covering of the head.80
Two special diseases evoked special defenses. “St. Anthony’s fire” was a skin ailment—perhaps erysipelas—so severe that an order of monks, the Congregation of the Antonines, was founded about 1095 to treat its victims. Leper hospitals are mentioned by Gregory of Tours (c. 560); the Order of St. Lazarus was organized to serve in these leprosaria. Eight diseases were regarded as contagious: bubonic plague, tuberculosis, epilepsy, scabies, erysipelas, anthrax, trachoma, and leprosy. A victim of any of these was forbidden to enter a city except under segregation; or to engage in selling food or drink. The leper was required to give warning of his approach by horn or bell. Usually his disease expressed itself in purulent eruptions on face and body. It was only mildly contagious, but probably medieval authorities feared that it could be spread by coitus. Possibly the term was used to include what would now be diagnosed as syphilis; but there is no certain reference to syphilis before the fifteenth century.81 No special provision seems to have been made for the care of the insane before the fifteenth century.
The Middle Ages, too poor to be clean or properly fed, suffered more than any other known period from epidemics. The “Yellow Plague” devastated Ireland in 550 and 664, killing, we are unreliably informed, two thirds of the population.82 Similar pestilences struck Wales in the sixth century, England in the seventh. A malady known to the French as mal des ardents—which was described as burning out the intestines—swept through France and Germany in 994, 1043, 1089, and 1130. Plagues of “leprosy” and scurvy may have come from returning Crusaders. The plica polonica, a disease of the hair, was apparently brought to Poland by the Mongol invasion of 1287. The harassed population ascribed these epidemics to famines, droughts, swarms of insects, astral influences, poisoning of wells by Jews, or the wrath of God; the likelier causes were the crowded condition of the small walled towns, poor sanitation and hygiene, and a consequent lack of defense against infections carried by returning soldiers, pilgrims, or students.83 We have no mortality statistics for the Middle Ages, but it is probable that not more than half of those born reached maturity. The fertility of women labors to atone for the stupidity of men and the bravery of generals.
Public sanitation improved in the thirteenth century, but never in the Middle Ages did it regain its excellence under Imperial Rome. Most cities and wards appointed officials to care for the streets,84 but their work was primitive. Moslem visitors to Christian towns complained—as Christian visitors now to Moslem towns—of the filth and smell of the “infidel cities.”85 At Cambridge, now so beautiful and clean, sewage and offal ran along open gutters in the streets, and “gave out an abominable stench, so… that many masters and scholars fell sick thereof.”86 In the thirteenth century some cities had aqueducts, sewers, and public latrines; in most cities rain was relied upon to carry away refuse; the pollution of wells made typhoid cases numerous; and the water used for baking and brewing was usually—north of the Alps—drawn from the same streams that received the sewage of the towns.87 Italy was more advanced, largely through its Roman legacy, and through the enlightened legislation of Frederick II for refuse disposal; but malarial infection from surrounding swamps made Rome unhealthy, killed many dignitaries and visitors, and occasionally saved the city from hostile armies that succumbed to fever amid their victories.