The Middle Ages

12 May

No simple characterization can describe the state of medical theory and practice in the European Middle Ages, a period from about 500 to 1500. However,   it  certainly   can  be  said  that   this  was  an  era  in  which ideas about  the nature  of the physical universe,  the nature  of human beings and their proper place in the universe, and, above all, their relationship  to their Creator  underwent  profound changes and disloca- tions. The formerly all-powerful Roman Empire, whose borders had encompassed  the  civilized Western  world  during  the  second  century, had undergone  its well-known ordeal of decline and fall after centuries of anarchy,  turmoil,  and warfare. Weakened by corruption, misgovern- ment,  and  insurrection, the  city of  Rome  lost  its role  as undisputed political  center of its crumbling  Empire.  In 330, Emperor  Constantine established  Byzantium  (Constantinople) as his capital.  By the  end  of the fourth  century,  the division of the empire between East  and  West had become permanent. The East was to become the Byzantine Empire and the West was to enter the era popularly  known as the Dark  Ages (a term fervently rejected by those who specialize in the study of medieval history). Historians generally described the Renaissance as a revolution- ary  period  in the  arts  and  sciences, which  finally  ended  hundreds  of years  of  intellectual  stagnation. Medievalists,  however,  have  rejected the  concept  of the  medieval  ‘‘Dark  Ages’’ and  claim  that  significant changes  in economic,  political,  and  social organizations were already occurring  somewhere between 1000 and  1250.

Within this disputed historical context, medieval medicine has been described as everything from a pathological  aberration to the dawn of a new chapter  in the evolution  of the medical profession.  In recent years, the literature  on medieval medicine has become vastly richer and more sophisticated, particularly with respect to its relationships with religion, education,  professional organizations, alternative practitioners, patterns of morbidity  and mortality,  and the persistence of the classical tradition. The  Middle  Ages  served  as  a  stage  for  many  remarkable  scholars, doctors,  and diseases, making  this period  both  unique and instructive.

The transition from Greco-Roman culture to medieval Christianity irrevocably  transformed the status  of the healing art.  The Hippocratic tradition based  on  love of the  art,  intellectual  curiosity,  glorification of the healthy  body,  and  the passionate  pursuit  of physical well-being were  foreign  to  the  spirit  of  the  medieval  Christian   world.  Indeed, powerful  theologians  like Tertullian  (160?–230?) could  explain  pesti- lence, famine,  wars,  and  natural disasters  as God’s  benevolent  means of pruning  the insolence of the human  race. As a branch  of learning, medicine, like all forms of secular learning,  was considered  inferior  to and subordinate to theology.  However, the actual  state of medicine as the necessary healing art,  rather  than  a branch  of learning  and  a pro- fession, is a more complex problem.  If it were true that  all sickness was the inexorable  consequence  of sin, or a test of faith,  suffering through such trials and tribulations might well be the theoretically  appropriate response.

For  the ancient Greeks,  the pursuit  of health was a worthy objec- tive, but seeking health  became problematic  within Christian  doctrine. The Greeks venerated health and regarded the human  body as beautiful and essentially god-like. Christians  were taught  to despise the flesh and its desires, but as the body housed the soul, or was a temple of God,  it deserved some measure of care and respect. Healing was good as an act of love; yet being  healed,  except  by God  and  His  servants,  was not necessarily  good.  Nevertheless,  religious  healing  and  secular  healing would have to coexist. Theologians  could explain disease as a form of punishment  or a test of faith, but the majority of people were not saints or ascetics. Medicine,  therefore,  continued  to be a part  of normal  life. With or without  theological rationalizations, the laity never abandoned the quest for health and healing, nor did physicians and scholars wholly abandon the secular Hippocratic tradition.

Hippocratic  medicine   won   varying   degrees   of   acceptance   in Europe  and  Byzantium.  Although  episodes of hostility  and  repression can  be discovered,  examples  of accommodation and  even respect  can also  be  documented. Followers  of  Hippocratic medicine  found  ways to accommodate their art, with varying degrees of success, to the world of Christian  beliefs. For their part, theologians  found ways to justify the worthiness  of healing  and  health,  and  the  study  of the  authoritative texts that contained  the ancient, secular knowledge essential to the prac- tice  of  medicine.  Setting  aside  major  theological  concerns  regarding body and soul, it could be argued that medicine was an art, like agricul- ture, architecture,  and weaving, that God had given to humankind. Moreover,  the  Hippocratic dietetic  tradition could  be rationalized  as another  means of the self-discipline essential to Christian life. As a hard- working  craftsman,   motivated   by  love  of  humankind, the  legendary Hippocrates  was  not  objectionable.   He  was  anathema  to  Christian dogma  if he was revered  as a healing  god  descended  from  Asclepius

and Apollo or as a savior who could perform  miracles of healing inde- pendent  of God  and His representatives.  The medieval physician could maintain  some degree of professional  autonomy and continue to honor the traditional wisdom of Hippocrates, but  he would have to learn  to award  ultimate  credit for any cures to God.

Theologians  divided  medicine into  two parts:  religious  medicine, concerned  with  ‘‘heavenly  things,’’  and  human   medicine,  concerned with  ‘‘earthly things.’’ Human  medicine  relied  on  empirical  methods such as dietary management, drugs, bleeding, and simple surgical opera- tions.  Religious  medicine  involved  prayers,  penitence,  exorcism,  holy relics, charms,  and incantations. The two parts  of medicine differed in origin and  efficacy: experience had  taught  physicians about  the power of  herbs,  but  Christ,  ‘‘the author of  heavenly  medicine,’’ could  cure the sick by his word alone and even raise the dead from the grave. Thus, the  Church,  which  acted  for  Christ,  could,  presumably,  heal  without earthly medicine.

Some of the early Church Fathers  taught that it was sinful to try to cure bodily ills by earthly medicines and that  the spirit of God was not found  in healthy  bodies.  Disease served as a test of faith  by forcing a choice between secular medicine and the Church.  However, it was also possible to argue that the body should be kept strong because those who were sick and weak might more easily succumb to Satan.  Moreover,  if disease was the punishment for sin and forgiveness was the province of the Church,  healing must  be a part  of the Church’s  mission of mercy and charity.  In any case, except for those who deliberately  chose mor- tification  of the flesh, there  is ample  evidence that  popes,  priests,  and peasants  sought  remedies for their pain and disease. As the cynic says, everyone wants to go to heaven, but no one wants to die.

Theologians  recorded  many miracle tales in which pious men and martyred  saints  cured  the  sick after  human  medicine  proved  useless. Medieval  scholars  believed that  the universe was governed  by general laws that  had  been  assigned  by God,  but  theologians  established  an important role for miracles. Priests might care for the sick with kindness and  recognize  the  medical  virtues  of  drugs,  but  every cure  was ulti- mately  a  miracle.  Healing  miracles  were often  ascribed  to  the  direct action  of saints  or  their  relics. Strictly  speaking,  ‘‘relic’’ refers to  the mortal remains of a saint, but the term was also used to describe objects that  had been in contact  with these holy persons.

By  the  fourth   century,  the  remains  of  certain  saints  were  the objects of public cults, despite the doubts expressed by some theologians as to the propriety  of honoring  such objects. Those who argued for the veneration  of  relics triumphed, and  the  increasing  popularity of  this form  of  worship  encouraged  the  discovery,  multiplication, and  theft of relics. The display of such obvious frauds as hairs from Noah’s beard, drops  of the Virgin’s milk, and other  wonders  was enough  to provoke the skepticism  of a saint.  In spite of the veritable  flood  of relics that washed over Europe  during the Crusades,  the insatiable demand  posed the threat  of a relic shortfall.  One solution  was to make a little bit of relic go a long way: the mortal  remains of saints and martyrs  were dis- membered so that the parts could be shared by several shrines. ‘‘Contact relics’’—water, cloths, or earth that had been in contact with the remains—could  also be venerated.  Theoretically,  the ‘‘fullness’’ of the saint  was  present  in  the  tiniest  fragment  of  relic or  ‘‘contact  relic.’’ When the need was acute, some relics were invested with the power of self-reproduction.

Miraculous cures were, of course, not uncommon incidents in the lives of  martyrs   and  saintly  kings.  For  example,  when  Edward   the Confessor washed the neck of a scrofulous, infertile woman, her scrofula disappeared   and  within  a  year  she  gave  birth  to  twins.  The  diluted blood of St. Thomas of Canterbury was said to cure blindness, insanity, leprosy, and deafness, but like their Egyptian and Roman  counterparts, most  saints  tended  to  specialize. The  martyred  brothers  Cosmas  and Damian, famous  for  their  skill in medicine  and  their  refusal  to  take payment  for their services, became the patron saints of physicians and pharmacists. According  to  traditional accounts,  the  twin  physicians were martyred  during  the reign of Roman  Emperor  Diocletian  in the early  fourth   century.   No  less an  authority than  Gregory   of  Tours (538–593), speaking  of the  miraculous  cures at  the  shrine  of Cosmas and  Damian  assured  the  sick that  ‘‘all who  prayed  in faith  departed healed.’’ Unlike many of the other texts of this genre, the stories dealing with Cosmas and Damian  often advised the sick to seek the aid of phy- sicians and healing saints. One of their more spectacular  cures involved grafting  the leg of a dead pagan  onto  one of their converts. In another episode,  the  saints  appeared  to  a physician  in a dream  and  told  him how to perform a surgical operation and apply healing drugs to a woman with  breast  cancer.  When  the  doctor  went  to  the  church  where  the woman had gone to pray to Cosmas and Damian, he found that the oper- ation had been miraculously performed. The saints left the final phase of treatment, the application of healing ointments,  to the physician.

Some  saints  became  associated  with  particular diseases  or  parts of the body  through  the manner  of their  death.  Because all her teeth had  been  knocked  out  during  her  martyrdom, St.  Apollonia  became patron saint  of toothache and  dentistry.  Portraits of St. Lucy, who is associated  with eye disorders,  show her holding  a dish containing  the eyes torn out by her persecutors.  Pestilential disease became the specialty of St. Sebastian  who had been wounded  but not killed by Diocletian’s archers.  Sebastian’s  recovery  from  the  attempted execution  suggested that  he was immune  to the arrows  of death.  In portraits of the saint, arrows pierce his body at the sites where plague buboes usually appear. An arrow  in the heart  symbolized the sudden death  that  often claimed plague victims. He was later sentenced to death by flogging. Women in labor  could  appeal  to Saint  Magaret,  who entered  the world  through the mouth  of a dragon.  Because of her miraculous  birth,  Margaret was the patron saint of women in childbirth.

Just as the pagan gods were replaced by Christian saints, the rituals of Asclepius were absorbed  into Christian  practice. Temples were trans- formed  into  churches  where the  worship  of Christ  the  Healer,  or  his healing saints, provided  a familiar setting for medical miracles. In con- trast  to the Asclepiads who excluded the incurable  from the sanctuary, the Church  took on the nursing of hopeless cases and promised relief in the next world if faith failed to effect an immediate  cure.

Theologians  generally mentioned  secular physicians only to show how relics and prayers were effective after earthy medicine failed. Given the bias of these authors, such stories can be looked upon as proof that the  sick often  turned  to  lay healers.  Medieval  writings  contain  many complaints  about  the physician’s love of ‘‘filthy lucre’’ and the high cost of medical care. John of Salisbury, for example, said that physicians were invariably  guided by two maxims: ‘‘Never mind the poor;  never refuse money from the rich.’’ On the other hand, biographies of medieval kings, nobles, and clergymen also refer to dedicated  physicians who won the respect and friendship  of their patrons.

In making his diagnosis, the medieval physician relied primarily on the patient’s narrative  of symptoms, but many healers were regarded as masters  of the  art  of uroscopy,  that  is, inspection  of urine.  Using  a specially  marked  flask,  the  physician  studied  the  color  of  the  urine and  the  distribution of  clouds,  precipitates,  and  particles  at  various levels of the flask in order  to  determine  the nature  of the illness and the condition  of the patient.  A story  about  the Duke  of Bavaria  indi- cates that  even in the  tenth  century,  some patients  were skeptics.  To test his physician, the Duke substituted the urine of a pregnant  woman for  his  own.  After  making   his  inspection,   the  physician   solemnly announced that  God was about  to bring about  a great event: the Duke would soon give birth  to a child.

The influence of the Church  on medical thought is only one aspect of the  way in which  the  Church  attained  a  virtual  monopoly  on  all forms of learning during the Middle Ages. The task of translating Greek medical texts into  Latin  had  begun by the fifth century.  For  the most part, the study of ancient texts and the preparation of extracts and com- pilations in the monasteries  reflect interest in logic and philology rather than  science, but there is evidence that  medical manuscripts  were con- sulted  for  practical  purposes.  Indeed,  the  marginal  comments  found on medical manuscripts  provide evidence of interest in applied medicine and pharmacology.

The  writings  of  certain  theologians,   such  as  Isidore,  Bishop  of Seville (ca. 560–636), provide  a good  example  of informed  interest  in medical  matters.   Isidore  believed  that  it  was  possible  to  use  pagan writings to prepare useful encyclopedic texts that would conform to Christian   faith   and   morals.   Such  studies  supported  the  idea  that medicine embraced  all the other  liberal disciplines of study.  Medicine was the art  of protecting, preserving,  and restoring  health  to the body by means of diet, hygiene, and  the treatment of wounds  and  diseases. However,  medicine was also a ‘‘second philosophy,’’  which cured  the body,  just  as the  first  philosophy  cured  the  soul.  Thus  the  physician had to be well grounded  in literature,  grammar, rhetoric,  and dialectic in order  to understand and explain difficult texts and study the causes and cures of infirmities in the light of reason.

Many  medical  manuscripts   were  written  in  the  form  of  a  dia-logue—the  format  used  in medieval  teaching,  but  medicine  was last, and  generally  least,  of  the  traditional four  faculties  of  the  medieval universities: theology, philosophy,  law, and medicine. Dialogues usually began  with a simple question,  such as: ‘‘What is medicine?’’ Students were   expected   to   memorize   standard  answers   and   the   teacher’s exposition  of  the  texts.  By the  ninth  century,  medieval  scholars  had established  the  concept  that  medical  studies  were an  integral  part  of Christian  wisdom. If all learning,  including the science of health,  came from God, the religious need not fear a conflict between the study of the medical literature  and theology. Medical knowledge could be enjoyed as an intellectual ornament, an area of serious study, and a potentially  use- ful technique.  Of course,  it was possible to  acknowledge  the value of classical medical texts while insisting that  health  could not be restored by herbs alone. The sick and their attendants must place their faith in God,  even as they attempted to find the proper  remedy.

Hospitals  have been called the greatest  medical innovation  of the Middle Ages, but  because the modern  hospital  is so closely associated with  advances  in research,  medical  education,  and  surgery,  the  term ‘‘hospital’’ conjures up images that are inappropriate to earlier time peri- ods. Certainly,  medieval hospitals  played an important social role, but their  primary  goals  were religious,  not  scientific. On  the  other  hand, the tendency to dismiss this era as the ‘‘Dark Ages’’ has created the false impression  that  the  medieval  hospital  was  invariably  a  terrible  pest house where the sick only went to die. Some medieval hospitals  appar- ently provided  comfort,  nursing,  and medical care as well as charity.

Confusion   about   the  origins  and  development   of  the  medieval hospital  reflects the paradoxes  and tensions of this complex era. Many hospitals  were no more than cottages, but in the major towns relatively large institutions served as infirmaries,  almshouses,  hostels,  and  leper houses. Of course, the number and nature of these charitable  enterprises changed  throughout the Middle  Ages. During  the fourteenth century, some hospitals  were trying to discharge the sick poor and replace them with paying clients, whereas others  became so intolerable  that  patients rebelled and demolished  them.

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