LATER MEDIEVAL MEDICINE
Medicine in the later Middle Ages, that is, from the tenth to the middle
of the fifteenth centuries, was greatly influenced by the medical schools
which arose in Italy and the West of Europe during this period. These were
organized mainly in connection with universities, Salerno, Montpellier,
Bologna, Paris, Padua, in the order of their foundations, so far as they
can be ascertained. These university medical schools represented serious
scientific teaching in medicine, and certainly were not more prone to
accept absurdities of therapeutics and other phases of supposed medical
knowledge than have been the universities of any other corresponding
period of time. Five centuries represent a very long interval in the
history of humanity, and provide opportunities for a great many curious
developments and ups and downs of interest, all of which must not be
considered as representing any particular generation or even century in
the history of that time. The absurdities came and went quite as in more
modern times; but all the while there was an undercurrent of solid medical
knowledge, founded on observation and definite clinical research,
superadded to the information obtained from the classics of medicine.
Even as early as the tenth century the thoroughly conservative teaching of
Salerno in medicine made itself felt, and above all counteracted the
Oriental tendencies to over-refinement of drugging, which had led to the
so-called calendar prescription. This was the most noteworthy element in
the medical practice of the later Middle Ages, but its significance has
been dwelt on in the chapter on Salerno and the Beginnings of Medical
History. While Arabic polypharmacy is the most striking feature of
Mohammedan influence on medicine at this time, there were a number of
Arabian and Jewish physicians who made a deep impression on the medicine
of the later Middle Ages--that is, subsequent to the tenth century. Their
work was felt not only in their own time, but for many subsequent
centuries even down to and beyond the Renaissance, and they therefore must
find a place in medieval medical history. This influence was exerted ever
so much more outside of Italy than in the Italian peninsula, where the
tradition of their contact with the original Greek authors still remained,
and where they were making medicine and surgery for themselves quite
apart from Arabian influence.
The more one knows about the conditions in Italian medicine the less
question is there of Arabian contributions to it. De Renzi in his History
of Italian Medicine makes it very clear that the Arabs exercised no
significant influence either at Salerno or elsewhere. The Benedictines and
Cassiodorus afford evidence of the study of the Greek medical classics in
Latin translations. Muratori cites a manuscript which he had consulted in
the Medicean Library at Florence, and which, though written between the
eighth and ninth centuries, says not a word of the Arabs and bears the
title of "Abstracts from Hippocrates, Galen, Oribasius, Heliodorus,
Asclepiades, Archigenes, Dioclis, Amyntas, Apollonius, Nymphiodorus,
Ruffius, Ephesinus, Soranus, Ægineta, and Palladius." These and not the
Arabs were the masters of the Italians, and it was fortunate, for the
world was thus saved many Arabian mistakes and their tendency to neglect
surgery. Before Salerno began to exert its real influence, some of the
Arabian physicians came to occupy places of prominence in the medicine of
the time.
The most important of these was Avicenna, born toward the end of the tenth
century in the Persian province of Chorasan, at the height of Arabian
influence. He is sometimes spoken of as the Arabian Galen. His famous
book, "The Canon," was the most consulted medical book throughout Europe
for centuries. There are very few subjects in medicine that did not
receive suggestive treatment at his hands. He has definite information
with regard to Bubonic plague and the _filaria medinensis_. He has special
chapters with regard to obesity, emaciation, and general constitutional
conditions. He has chapters on cosmetics and on affections of the hair and
nails that are interesting reading. The Renaissance scholars wrote many
commentaries on his work, and for long after the introduction of printing
his influence was felt widely.
His Arabic colleague in the West was Avenzoar, to call him by the
transformation of his Arabic family name, Ibn-Zohr. He was born near
Seville, and probably died there, in 1162, well past ninety years of age.
He was the teacher of Averröes, who always speaks of him with great
respect. He is interesting as probably the first to suggest nutrition per
rectum. His apparatus for the purpose consisted of the bladder of a goat
with a silver cannula fastened into its neck. Having first carefully
washed out the rectum with cleansing and purifying clysters, he injected
the nutriment--eggs, milk, and gruel--into the gut. His idea was that the
intestine would take this and, as he said, suck it up, carrying it back to
the stomach, where it would be digested.
The bladders of animals were very commonly used by these Moorish
physicians and by their disciples, and the profession generally, for
generations, for a great many purposes for which we now use rubber bags.
Abulcasis, for instance, used a sheep's bladder introduced into the vagina
and filled with air as a colpeurynter for supporting the organs in the
neighbourhood, and also in fractures of the pubic arch.
Avenzoar suggested feeding _per rectum_ in cases of stricture of the
oesophagus, but he also treated the oesophageal stricture directly. He
inserted a cannula of silver through the mouth until its head met an
obstruction. This was pushed firmly, but withdrawn whenever there was a
vomiting movement, until it became engaged in the stricture. Through it
then _freshly milked_ milk, or gruel made from farina or barley, was to be
poured. He had evidently seen cases improve this way, and therefore must
have had experience with functional stricture of the oesophagus. He adds
that some physicians believe that nutrition may be absorbed through the
pores of the whole body, and that therefore in these cases the patient
might be put in a warm milk or gruel bath; but he has not very much faith
in the procedure, and says that the reasons urged for it are weak and
rather frivolous. It is easy to understand that a man who could recommend
manipulative modes of treatment of such kinds, and discuss questions of
nutrition so sensibly, knew his medicine very practically and wrote of it
judiciously.
Maimonides (1135-1204) was one of these wise old Jews who quotes with
approval from a Rabbi of old who had counselled his students: "Teach thy
tongue to say, I do not know." Knowing thus the limitations of his own
knowledge, it is not surprising that Maimonides should have left a series
of practical observations for the maintenance of health which represent
the common sense of all time in the matter. Maimonides anticipated the
modern rule for taking fruits before meals, as we all do now at breakfast,
and so often as fruit cocktails at the beginning of other meals. He
thought that grapes, figs, melons, should be taken before meals, and not
mixed with other food. He set down as a rule that what was easily
digestible should be eaten at the beginning of the meal, to be followed by
what was more difficult of digestion. He declared it to be an axiom of
medicine "that so long as a man is able to be active and vigorous, does
not eat until he is over full, and does not suffer from constipation, he
is not liable to disease."
Salerno's influence was felt much more deeply on surgery than on medicine,
as can be seen very clearly from the chapter on Medieval Surgeons--Italy.
These great surgeons of the period were also the leaders in medicine--for
almost needless to say, there was no separation between the two modes of
practice--men were as a rule both physicians and surgeons, even though for
us their most important work by far was done in surgery. Certain passages
from the works of these great surgeons that have come down to us deserve a
place in the treatment of the more distinctly medical questions of the
time.
Lanfranc the great French surgeon's description of the treatment of the
bite of a rabid dog is interesting. He suggests that a large cupping-glass
should be applied over the wound, so as to draw out as much blood as
possible. After this the wound should be dilated and thoroughly cauterized
to its depths with a hot iron. It should then be covered with various
substances that were supposed "to draw," in order as far as possible to
remove the poison. His description of how one may recognize a rabid animal
is rather striking in the light of our present knowledge, for he seems to
have realized that the main diagnostic element is a change in the
disposition of the animal, but above all a definite tendency to lack
playfulness. Lanfranc had manifestly seen a number of cases of true
rabies, and describes and suggests treatment for them, though evidently
without very much confidence in the success of the treatment.
The treatment of snake-bites and the bites of other animals supposed to be
poisonous, or at least suspicious, followed the principles laid down for
handling the bite of a mad dog. This was the case particularly as to the
encouragement of free bleeding and the use of the cautery.
A characteristic example of the power of clinical observation of the
medieval physicians, and one which illustrates much better than many of
the absurd tales told as typical of their superstitious tendencies, but
really representing that tendency always present in mankind to believe
wonders, is to be found in how much they learned of rabies. Even in our
own time there are many absurd beliefs with regard to this disease, with
some denials of its existence and many grossly exaggerated tales, widely
believed; yet the medieval people seem to have reached some quite rational
notions with regard to it. Bartholomæus Anglicus is the author of a
popular encyclopedia which was very widely read in the medieval period. He
was an English Franciscan of the thirteenth century, who gathered together
a lot of information and wrote a volume that for centuries after his
time, even down to Shakespeare's boyhood, was popular in England.
Here is his description of rabies as he knew it. The most important
element is his recognition of the uncertainty of the length of the
incubation period, but it contains two other ideas that are very
interesting, because medicine in subsequent centuries has come back to
them over and over again. One is that free bleeding may remove the virus,
and the other that the cautery may help in preventing the infection.
"The biting of a wood-hound is deadly and venomous, and such venom is
perilous. For it is long hidden and unknown, and increaseth and
multiplieth itself, and is sometimes unknown to the year's end, and
then the same day and hour of the biting it cometh to the head, and
breedeth frenzy. They that are bitten of a wood-hound have in their
sleep dreadful sights, and are fearful, astonished, and wroth without
cause. And they dread to be seen of other men, and bark as hounds, and
they dread water most of all things, and are afeared thereof, full
sore and squeamous also. Against the biting of a wood-hound wise men
and ready use to make the wounds bleed with fire or with iron, that
the venom may come out with the blood that cometh out of the wound."
A very interesting development of therapeutics in the Middle Ages was the
employment of the red light treatment to shorten the course and the
severity of the fever in smallpox, and above all to prevent pitting; it
was employed successfully by John of Gaddesden in the case of the son of
King Edward II. Recent investigation by Cholmeley has shown that both
Gilbertus Anglicus (1290) and Bernard de Gordon (1305) antedated John of
Gaddesden in references to the red light treatment. All of these men were
professors at Montpellier, showing that the medical school of the South of
France was a rival in the use of natural methods of cure to its
better-known predecessor of Southern Italy. Curiously enough, the "Rosa
Anglica" of Gaddesden, in which the reference to the red light is made, is
deservedly characterized by Garrison as "a farrago of Arabist quackeries
and countrified superstitions"; it well deserves Guy de Chauliac's bitter
criticism of it as "a scentless rose."
The idea included under the word autointoxication in our time--that is,
that the human body has a tendency to produce poisons within itself, which
act deleteriously on it and must be eliminated--was a favourite one during
the Middle Ages. It became the custom in our time to have recourse to
antiseptics or to surgical measures of various kinds for the relief and
prevention of autointoxication. In the Middle Ages they thought to reduce
its harmfulness at least by direct elimination, hence the use of drastic
purgatives. It seems worth while remarking, however, that the employment
of these did not come into general use until the close of the Middle Ages.
Basil Valentine, if he really lived in the Middle Ages, and is not merely
a name for a writer of the early sixteenth century, as modern historians
seem inclined to think, suggested the use of antimony for the removal of
the materies morbi from the body that has so much obsessed physicians for
many generations. Antimony continued to be used down to the nineteenth
century. It was gradually replaced by venesection, which was employed very
strenuously during the eighteenth and early nineteenth centuries, in spite
of the objection of such men as Morgagni, who refused to allow this mode
of treatment to be used on him.
Venesection was succeeded by large doses of calomel, and the calomel era
continued on almost to our own generation.
As a rule, however, the medieval physicians trusted nature much more than
did their colleagues of modern history--that is, after the Renaissance
until the present epoch of medical science began. It has always been
difficult, however, for physicians to continue long in the persuasion that
nature is a helpful auxiliary, and not a hampering factor to be combated.
It is all the more to the credit of the medieval physicians to find,
then, that in spite of many absurdities they continued for all the later
centuries of the Middle Ages to extol the value of the natural means of
cure.
I shall have much to say of John of Ardern in the chapter on Medieval
Surgeons of the West of Europe, but he deserves a place also in the
chapter on Medicine. Ardern's advice to patients suffering from renal
disease, which is contained in a separate tract of his lesser writings
with the title in an old English version of "The Governaunce of
Nefretykes," is extremely interesting, because it shows very clearly how
long ago thoughtful physicians anticipated most of the directions that we
now give such patients. Though we are inclined to think that any real
knowledge of renal disease is quite modern, and above all has come since
Bright's time, this paragraph of Ardern's shows how long before definite
pathological knowledge had developed, careful clinical observation worked
out empirically the indications of the affection. The paragraph is of
special interest, because it contains the first reference to the possible
danger that there may be for sufferers from kidney disease using the dark
or red meats rather than the white meats. The tradition as to the
distinction between the red and white meats has continued ever since his
time, and though our modern chemistry does not enable us to find any such
distinction between these substances as would justify the differentiation
thus dwelt on, it has been maintained for no other reason that I have ever
been able to find than because of the long years of tradition and clinical
observation behind it.[6]
"Nefretykes must putte awey ire, hyghly and moche besynesse and
almanere [business and all manner of] thynge that longeth to the soule
saff [save] only joye.... They schulle forbere almanere metys that ben
to grete of substaunse and viscous, as olde beeff that is myghtyly
pooudryd and enharded with salt and also fressch porke but yf it lye
in salt iiii dayes afore.... They mowe use grete wyne and the fflessch
of calvys that ben soowkynge and also of all ffowlys saff thoo that
ben of the lakys and dichys [dykes?] ... and squamous ffyssches, i.e.,
fyssch of the rivere, of the stony waterys and rennynge ryveres and
not of the standyne waterys and they schulle eschywe [eschew] almaner
mete made of paast [pastries] and all bred that is dowgh bakene and
all fatnesse. And they schulle use the reynes of te beeste other roste
or sode. And in especiall he schall use a ffowl that is callyd Cauda
tremula or Wagstertte [the wagtail, an English bird] other fressch or
salte or bakene withoute drynesse ffor and it be drye it is nought
woorth. And note that the use of the powdir or of the flessch of the
Wagstertte avayleth gretly to breke the stone in the bladdere."[7]