EARLY MEDIEVAL MEDICINE
There are two distinct periods in the history of Medieval Medicine. The
first concerns the early centuries, from the sixth to the ninth, and is
occupied mainly with the contributions to medicine made by those who were
still in touch with the old Greek writers; while the second represents the
early Renaissance, when the knowledge of the Greek writers was gradually
filtering back again, sometimes through the uncertain channel of the
Arabic. Both periods contain contributions to medicine that are well
worthy of consideration, and nearly always the writings that have been
preserved for us demonstrate the fact that men were thinking for
themselves as well as studying the Greek writers, and were making
observations and garnering significant personal experience. The later
Middle Ages particularly present material in this regard of far greater
interest than was presumed to exist until comparatively recent historical
studies were completed.
The real history of medicine in the Middle Ages--that is, of scientific
medicine--is eclipsed by the story of popular medicine. So much has been
said of the medical superstitions, many of which were rather striking,
that comparatively little space has been left for the serious medical
science and practice of the time, which contain many extremely interesting
details. It is true that after the Crusades mummy was a favourite
pharmacon, sometimes even in the hands of regular physicians; and _Usnea_,
the moss from the skulls of the bodies of criminals that had been hanged
and exposed in chains, was declared by many to be a sovereign remedy for
many different ills; but it must not be forgotten that both of these
substances continued to be used long after the medieval period, mummy even
down to the middle of the eighteenth century, and Usnea almost as late.
Indeed, it is probable that the seventeenth and eighteenth centuries
present many more absurdities in therapeutics than do the later centuries
of the Middle Ages. In this, as in so many other regards, the modern use
of the adjective medieval has been symbolic of ignorance of the time
rather than representative of realities in history.
Popular medicine is always ridiculous, though its dicta are often accepted
by supposedly educated people. This has always been true, however, and was
never more true than in our own time, when the vagaries of medical faddism
are so strikingly illustrated, and immense sums of money spent every year
in the advertising of proprietary remedies, whose virtues are often sadly
exaggerated, and whose tendency to work harm rather than good is
thoroughly appreciated by all who know anything about medicine. The
therapeutics of supposedly scientific medicine are often dubious enough. A
distinguished French professor of physiology quoted, not long since, with
approval, that characteristic French expression: "The therapeutics of any
generation are always absurd to the second succeeding generation." When we
look back on the abuse of calomel and venesection a century ago, and of
the coal-tar derivatives a generation ago, and the overweening confidence
in serums and vaccines almost in our own day, it is easy to understand
that this law is still true. We can only hope that our generation will not
be judged seven centuries from now by the remedies that were accepted for
a time, and then proved to be either utterly ineffectual or even perhaps
harmful to the patients to whom they were given.
When we turn our attention away from this popular pseudo-history of
Medieval Medicine, which has unfortunately led so many even well-informed
persons into entirely wrong notions with regard to medical progress during
an important period, we find much that is of enduring interest. The first
documents that we have in the genuine history of Medieval Medicine, after
the references to the organizations of Christian hospitals at Rome and
Asia Minor in the fourth and fifth centuries (see chapter Medieval
Hospitals), are to be found in the directions provided in the rules of the
religious orders for the care of the ailing. St. Benedict (480-543), the
founder of the monks of the West, was particularly insistent on the
thorough performance of this duty. The rule he wrote to guide his
religious is famous in history as a great constitution of democracy, and
none of its provisions are more significant than those which relate to the
care of the health of members of the community.
One of the rules of St. Benedict required the Abbot to provide in the
monastery an infirmary for the ailing, and to organize particular care of
them as a special Christian duty. The wording of the rule in this regard
is very emphatic. "The care of the sick is to be placed above and before
every other duty, as if, indeed, Christ were being directly served in
waiting on them. It must be the peculiar care of the Abbot that they
suffer from no negligence. The Infirmarian must be thoroughly reliable,
known for his piety and diligence and solicitude for his charge." The last
words of the rule are characteristic of Benedict's appreciation of
cleanliness as a religious duty, though doubtless also the curative effect
of water was in mind. "Let baths be provided for the sick as often as they
need them." As to what the religious infirmarians knew of medicine, at
least as regards the sources of their knowledge and the authors they were
supposed to have read, we have more definite information from the next
historical document, that concerning medical matters in the religious
foundation of Cassiodorus.
Cassiodorus (468-560), who had been the prime minister of the Ostrogoth
Emperors, when he resigned his dignities and established his monastery at
Scillace in Calabria, was influenced deeply by St. Benedict, and was
visited by the saint not long after the foundation.
His rule was founded on that of the Benedictines. Like that, it insisted
especially on the care of the sick, and the necessity for the deep study
of medicine on the part of those who cared for them. Cassiodorus laid down
the law in this regard as follows: "I insist, brothers, that those who
treat the health of the body of the brethren who have come into the sacred
places from the world should fulfil their duties with exemplary piety. Let
them be sad with others' suffering, sorrowful over others' dangers,
sympathetic to the grief of those whom they have to care for, and always
ready zealously to help others' misfortunes. Let them serve with sincere
study to help those who are ailing as becomes their knowledge of medicine,
and let them look for their reward from Him who can compensate temporal
work by eternal wages. Learn, therefore, the nature of herbs, and study
diligently the way to combine their various species for human health; but
do not place your entire hope on herbs, nor seek to restore health only by
human counsels. Since medicine has been created by God, and since it is He
who gives back health and restores life, turn to Him. Remember, do all
that you do in word or deed in the name of the Lord Jesus, giving thanks
to God the Father through Him. And if you are not capable of reading
Greek, read above all the translations of the Herbarium of Dioscorides,
which describes with surprising exactness the herbs of the field. After
this, read translations of Hippocrates and Galen, especially the
Therapeutics, and Aurelius Celsus' 'De Medicina,' and Hippocrates' 'De
Herbis et Curis,' and divers other books written on the art of medicine,
which by God's help I have been able to provide for you in my library."
The monasteries are thus seen to have been in touch with Greek medicine
from the earliest medieval time. The other important historical documents
relating to Medieval Medicine which we possess concern the work of the
men born and brought up in Asia Minor, for whom the Greeks were so close
as to be living influences. Aëtius, Alexander of Tralles, and Paul of
Ægina have each written a series of important chapters on medical
subjects, full of interest because the writers knew their Greek classic
medicine, and were themselves making important observations. Aëtius, for
instance, had a good idea of diphtheria. He speaks of it in connection
with other throat manifestations under the heading of "crusty and
pestilent ulcers of the tonsils." He divides the anginas generally into
four kinds. The first consists of inflammation of the fauces with the
classic symptoms; the second presents no inflammation of the mouth nor of
the fauces, but is complicated by a sense of suffocation--apparently our
neurotic croup. The third consists of external and internal inflammation
of the mouth and throat, extending towards the chin. The fourth is an
affection rather of the neck, due to an inflammation of the
vertebræ--retropharyngeal abscess--which may be followed by luxation, and
is complicated by great difficulty of respiration. All of these have as a
common symptom difficulty of swallowing. This is greater in one variety
than in another at different times. In certain affections he remarks that
even "drinks when taken are returned through the nose."
Aëtius declares quite positively that all the tumours of the neck region,
with the exception of scirrhus, are easily cured, yielding either to
surgery or to remedies. The exception is noteworthy. He evidently saw a
good many of the functional disturbances and the enlargements of the
thyroid gland, which are often so variable in character as apparently to
be quite amenable to treatment, and which have actually been "cured" in
the history of medicine by all sorts of things from the touch of the
hangman's rope to the wrapping of the shed skin of the snake around the
neck. A few cervical tumours were beyond resource. Aëtius suggests the
connection between hypertrophy of the clitoris and certain exaggerated
manifestations of the sexual instinct, as well as the development of
vicious sexual habits.
It requires only a little study of this early medieval author to
understand why Cornelius, at the time of the Renaissance, was ready to
declare: "Believe me, that whoever is deeply desirous of studying things
medical, if he would have the whole of Galen abbreviated and the whole of
Orbiasius extended, and the whole of Paulus (of Ægina) amplified; if he
would have all the special remedies of the old physicians, as well in
pharmacy as in surgery, boiled down to a summa for all affections, he will
find it in Aëtius."
Alexander of Tralles was, as we have said, the brother of the architect of
Santa Sophia of Constantinople, and his writings on medical and surgical
subjects are worthy of such a relationship. His principal work is a
treatise on the "Pathology and Therapeutics of Internal Diseases" in
twelve books, the first eleven books of which were evidently material
gathered for lectures or teaching purposes. He treats of cough as a
symptom due to hot or cold, dry or wet, dyscrasias. Opium preparations
judiciously used he thought the best remedies, though he recommended also
the breathing in of steam impregnated with various ethereal resins.
He outlines a very interesting because thoroughly modern treatment of
consumption. He recommends an abundance of milk with a hearty nutritious
diet, as digestible as possible. A good auxiliary to this treatment in his
opinion was change of air, a sea voyage, and a stay at a watering-place.
Ass's and mare's milk are much better for these patients than cow's and
goat's milk. We realize now that there is not enough difference in the
composition of these various milks to make their special prescription of
physical importance, but it is probable that the suggestive influence of
the taking of an unusual milk had a very favourable effect upon patients,
and this effect was renewed with every drink taken, so that much good was
ultimately accomplished. For hæmoptysis, especially when it was acute and
due, as Alexander felt, to the rupture of a bloodvessel in the lungs, he
recommended the opening of a vein at the elbow or the ankle--in order to
divert the blood from the place of rupture to the healthy parts of the
circulation. He insisted, however, that the patients must in addition
rest, as well as take acid and astringent drinks, while cold compresses
should be placed upon the chest [our ice-bags], and that they should take
only a liquid diet, at most lukewarm, or, better, if agreeable to them,
cold. When the bleeding stopped, he declared a milk cure [blood-maker]
very useful for the restoration of these patients to their former
strength.
He paid particular attention to diseases of the nervous system, and
discussed headache at some length. Chronic or recurrent headache he
attributed to diseases of the brain, plethora, biliousness, digestive
disturbances, insomnia, and prolonged worry. Hemicrania he thought due to
the presence of toxic materials, though it was also connected with
abdominal disorders, especially in women. Alexander has much to say of the
paralytic and epileptic conditions, and recommended massage, rubbings,
baths, and warm applications for the former, and emphasized the need for
careful directions as to the mode of life, and special attention to the
gastro-intestinal tract, in the latter. A plain, simple diet, with regular
bowels, he considers the most important basis for any successful treatment
of epilepsy. Besides, he recommended baths, sexual abstinence, and regular
exercise. He rejected treatment of the condition by surgery of the head,
either by trephining or by incisions or by cauterization. His teaching is
that of those who have had most experience with the disease in our own
time. For sore throat he prescribes gargles or light astringents at the
beginning, and stronger astringents, alum and soda dissolved in water,
later in the case.
He particularly emphasized that trust should not be placed in any single
method of treatment. Every available means of bringing relief to the
patient should be tried. "The duty of the physician is to cool what is
hot, to warm what is cold, to dry what is moist, and to moisten what is
dry. He should look upon the patient as a besieged city, and try to rescue
him with every means that art and science placed at his command. The
physician should be an inventor, and think out new ways and means by which
the cure of the patient's affection and the relief of his symptoms may be
brought about." The most important factor in Alexander's therapeutics is
his diet. Watering-places and various forms of mineral waters, as well as
warm baths and sea baths, are constantly recommended by him. He took
strong ground against the use of many drugs, and the rage for operating.
The prophylaxis of disease is in Alexander's opinion the important part of
the physician's duty. His treatment of fever shows the application of his
principle: cold baths, cold compresses, and a cooling diet, were his
favourite remedies. He encouraged diaphoresis nearly always, and gave wine
and stimulating drugs when the patient was very weak.
Some of the general principles of medical practice which Alexander lays
down are very significant even from our modern standpoint. He deprecated
drastic remedies of all kinds. He did not believe in severe purgation nor
in profuse or sudden blood-letting. His diagnosis was thorough and
careful. He insisted particularly on inspection and palpation of the whole
body; on careful examination of the urine, of the fæces, and the sputum;
on study of the pulse and the breathing. He dwelt on the fact that much
might be learned from the patient's history taken carefully. The general
constitution was the most important element, in his estimation. His
therapeutics is, above all, individual. Remedies must be administered with
careful reference to the constitution, the age, the sex, and the condition
of the patient's strength. Special attention must always be paid to
seconding nature's efforts to cure. Alexander had no sympathy at all with
the idea that nature was to be disturbed, much less that remedies must
work in opposition to natural tendencies to recovery.
Paul of Ægina, educated at the University at Alexandria, probably
flourished during the reign of the Emperor Heraclius, who died 641; his
works contain more of surgical than of medical interest.
The Arab writer, Abul Farag, to whose references we owe the definite
placing of the time when Paul lived, said that "he had special experience
in women's diseases, and had devoted himself to them with great industry
and success. The midwives of the time were accustomed to go to him and ask
his counsel with regard to accidents that happen during and after
parturition. He willingly imparted his information, and told them what
they should do. For this reason he came to be known as the Obstetrician."
Perhaps the term should be translated the man-midwife, for it was rather
unusual for men to have much knowledge of this subject. His knowledge of
the phenomena of menstruation was wide and definite. He knew a great deal
of how to treat its disturbances. He seems to have been the first one to
suggest that in metrorrhagia, with severe hæmorrhage from the uterus, the
bleeding might be stopped by putting ligatures around the limbs. This
same method has been suggested for severe hæmorrhage from the lungs as
well as from the uterus in our own time. In hysteria he also suggested
ligature of the limbs, and it is easy to understand that this might be a
very strongly suggestive treatment for the severer forms of hysteria. It
is possible, too, that the modification of the circulation to the nervous
system induced by the shutting off of the circulation in large areas of
the body might very well have a favourable physical effect in this
affection. Paul's description of the use of the speculum is as complete as
that in any modern textbook of gynæcology.
In the chapter on the medieval care of the insane, there are some clinical
observations and suggestions as to treatment from Paul which make it very
clear what a careful observer he was, and how rational in his application
of such knowledge as he had to the treatment of patients. Probably his
contributions to the difficult subject psychiatry, well above a thousand
years ago, will serve to make his genius as a physician clearer than
almost anything else that could be said of him.
Among the great Arabian physicians who represent the transition period,
from the earlier Middle Ages directly under Greek influence, still
surviving to the later Middle Ages, when the earlier Renaissance brought
back the Greek masters once more, were Rhazes, Ali Abbas, Avicenna--whose
name had been transformed from the Arabic Ibn Sina--Abulcasis, Avenzoar,
and Averroes, the last named a philosophic theorist but not a physician.
The first three named were born in the East, the last three in Spain.
Besides these Maimonides, the great Jewish physician, who was born and
educated at Cordova in Spain, deserves a place. In this earlier period
Rhazes must be mentioned, while the others who merit special attention
will be considered in the chapter on Later Medieval Medicine.
Rhazes (died 932) is one of the great epoch-makers in the history of
medicine. He was the first to give us a clear description of smallpox.
Some of his medical aphorisms are well worth noting, and make it very
clear that he was a careful observer.
"When you can heal by diet, prescribe no other remedy; and where simple
remedies suffice, do not take complicated ones."
Rhazes knew well the value of the influence of mind over body even in
serious organic disease, and even though death seemed impending. One of
his aphorisms is: "Physicians ought to console their patients even if the
signs of impending death seem to be present." He considered the most
valuable thing for the physician to do was to increase the patient's
natural vitality. Hence his advice: "In treating a patient, let your first
thought be to strengthen his natural vitality. If you strengthen that, you
remove ever so many ills without more ado. If you weaken it, however, by
the remedies that you use, you always work harm." The simpler the means by
which the patient's cure can be brought about, the better in his opinion.
He insists again and again on diet rather than artificial remedies. "It is
good for the physician that he should be able to cure disease by means of
diet, if possible, rather than by means of medicine." Another of his
aphorisms seems worth while quoting: "The patient who consults a great
many physicians is likely to have a very confused state of mind."
During the ninth and tenth centuries the Arabs continued to be the most
important contributors to medicine, until the rise of the school at
Salerno gave a new impetus to clinical observation, and furnished a new
focus of medical attention in the West. Constantine brought whatever of
Arab influence there was in Salerno, as we have pointed out in the chapter
on the Beginnings of Medical Education; but after his time there is an
originality about Salernitan medicine which makes it of great value as the
foster-mother of the sciences related to medicine during the later Middle
Ages.