Dispelling Some Myths: Medieval medical knowledge

Despite the best efforts of historians, the internet is still awash with misconceptions about the Middle Ages. Many of these ideas were the product of Victorian writers and historians reflecting Mediæval life through the lens of their own society, as was done by antiquarians before and by historians since. However, after more than a century in popular culture, and having been taught in schools, these sometimes broad, sweeping assertions remain deeply rooted in everyday consciousness, especially when repeatedly reinforced online, in social media, on television and in the movies. Before addressing one such notion, it is worth remembering that the Mediæval period lasted roughly 1,000 years during which peoples’ lives and experiences varied according to time, place and circumstance.

No medical knowledge Into the early years of the 20th-century most historians were seemingly content to accept the concept of a “Dark Age” in the centuries after the collapse of the Western Roman Empire. It was an idea that originated with the Italian scholar Petrarch [1] in the 1330s. He regarded the post-Roman centuries as “dark” full of ignorance and error compared to the “light” of classical antiquity with its knowledge and understanding. The term “Dark Age(s)” comes from the Latin phrase saeculum obscurum which was originally applied, in 1602, by Caesar Baronius to the turbulent period of the 10th- and 11th-centuries. The concept was expanded to characterise the entire Middle Ages as a time of intellectual darkness in Europe between the fall of Rome and the Renaissance. With that in mind, some have assumed that Mediæval doctors had little idea of what they were doing and that all classical Greco-Roman knowledge had been lost. Clearly modern medicine has benefited from centuries of innovation in technology triggering original research, new medical techniques, novel drugs and medicines. Yet, Mediæval hospitals were clean and well managed, and skeletons show examples of complicated medical procedures that were successful.

Enduring practices Mediæval medicine benefitted greatly from the work of Aelius Galenus (or possibly Claudius Galenus), whose name is often anglicised as Galen of Pergamon to reflect the city of his birth (present-day Bergama, Türkiye). He was a physician, surgeon and philosopher [2]. The son of a wealthy architect, he was educated as a philosopher but with Pergamum housing a magnificent shrine to the healing god Asclepius, at the age of 16 Galen changed his career to that of medicine. Initially studying in Pergamum, his training continued in Smyrna (modern İzmir, Türkiye), and finally in Alexandria, Egypt, which at the time was the greatest medical centre of the ancient world. After more than a decade of study, in AD 157 he returned to Pergamum where he served as chief physician to the troop of gladiators maintained by the high priest of Asia.

His extensive travels exposed him to a wide variety of medical theories and discoveries before he eventually settled in Rome in AD 162. Once there Galen served prominent members of Roman society until, in AD 168–169, he was called by the joint emperors Lucius Verus and Marcus Aurelius to accompany them on a military campaign in northern Italy. After Verus’ sudden death in AD 169, Galen returned to Rome where he went on to serve as a personal physician to Marcus Aurelius and the later emperors Commodus and Septimius Severus. Considered to be one of the most accomplished of all medical researchers of antiquity, he influenced the development of various scientific disciplines, including anatomy, neurology, pathology, pharmacology, physiology, as well as philosophy and logic. Of those disciplines Galen regarded anatomy as the foundation of medical knowledge. He frequently dissected and experimented on animals such as Barbary apes (or African monkey), pigs, sheep, and goats. Galen’s advocacy of dissection, both to improve surgical skills and for research purposes, was a large part of his self-promotion, but his accounts prove he was an accurate observer. He distinguished seven pairs of cranial nerves, described the valves of the heart, and observed the structural differences between arteries and veins. Most significantly he demonstrated that the arteries carry blood, not air, as had been taught for 400 years. Unfortunately the prevailing taboo on human dissection meant much of Galen’s understanding of human anatomy was based upon his dissections of animals. Unsurprisingly this led Galen to make mistakes. His anatomy of the uterus, for example, is largely that of a dog’s.

Galen’s understanding of physiology was constructed from the philosophers Plato and Aristotle as well as the physician, Hippocrates. Building on the latter’s ideas, Galen conceived that human health required a balance between the four main bodily fluids known as humours. Each corresponds to one of the traditional four temperaments. Blood was associated with a sanguine nature (enthusiastic, active, and social), while yellow bile caused a choleric nature (ambitious, decisive, aggressive, and short-tempered). Black bile was associated with a melancholy nature, with the word melancholy being derived from the Greek for “black bile” namely μέλαινα χολή (melaina kholé). As its name suggests, phlegm was associated with a phlegmatic behaviour. People with this temperament may be reserved, thoughtful, reasonable, calm, patient, caring, and of a tolerant nature. Based on Hippocratic medicine, it was believed that for a body to be healthy, the four humours should be balanced in amount and strength. The proper blending and balance of the four humours was known as eukrasia. Galen also related a correspondence between humours and seasons based on the properties of both. Blood, as a humour, was considered hot and wet and thus corresponded with spring. Yellow bile was considered hot and dry, which related it to summer. Black bile was considered cold and dry and thus related to autumn, and phlegm being cold and wet was related to winter. This was a system of medicine detailing a supposed makeup and workings of the human body, is known as humourism (or the humoral theory) dominated medical thinking for the next 1,400 years.

During his lifetime, Galen’s writings were widely circulated. His final medical treatises were written after AD 207, evidence that his Arab biographers were probably correct when claiming he died in AD 216/217 at the age of 87. Copies of some of his surviving works were produced within a generation of his death, and by AD 500 Galen’s theories were being taught and summarised at Alexandria to the exclusion of others in the medical handbooks of the Byzantine world. Greek manuscripts began to be collected and translated by enlightened Arabs in the 9th-century. About AD 850 Ḥunayn ibn Isḥāq, an Arab physician at the court of Baghdad, prepared an annotated list of 129 works of Galen that he and his followers had translated from Greek into Arabic or Syriac. Learned medicine in the Arabic world thus became heavily based upon the commentary, exposition, and understanding of Galen. Here his authority was long-lived but initially, except for drug recipes, Galen’s influence was almost negligible in western Europe.

From the late 11th-century, however, Ḥunayn ibn Isḥāq’s translations, commentaries on them by Arab physicians, and sometimes the original Greek writings themselves were translated into Latin. These Latin versions came to form the basis of medical education in the new medieval universities. Around 1490, Italian humanists felt compelled to prepare new Latin versions of Galen directly from Greek manuscripts to free his texts from medieval preconceptions and misunderstandings. Galen’s works were first printed in Greek in their entirety in 1525, and printings in Latin swiftly followed. Such Renaissance texts presented Galen differently and emphasized Galen as a clinician, a diagnostician, and above all, an anatomist. His new followers stressed his methodical techniques of identifying and curing illness, his independent judgment, and his cautious empiricism. Galen’s injunctions to investigate the body were eagerly followed, since physicians wished to repeat the experiments and observations that he had recorded. Paradoxically, this soon led to the overthrow of Galen’s authority as an anatomist. In 1543 the Flemish physician Andreas Vesalius showed that Galen’s anatomy of the body was more animal than human in some of its aspects, and it became clear that Galen and his subsequent mediæval followers had made many errors. Galen’s notions of physiology, by contrast, lasted for a further century, until in 1628 the English physician William Harvey correctly explained the circulation of the blood. Eventually, in 1673 Antonie van Leeuwenhoek discovery, using simple single-lensed microscopes of his own design, and his subsequent scientific experiments with microorganisms finally put paid to Galen’s dominance. Yet, the mediæval renewal of the Galenic tradition, followed by the challenges to his theories in Renaissance Europe, were significant for the advancement of modern science.

Mediæval progress When the Western Roman Empire collapsed some Greek and Roman medical knowledge was inevitably lost but progress in medicine did not come to an abrupt stop. Quite a few advancements in surgery, medical chemistry, dissection, and practical medicine were made in the Mediæval era. As Theodoric of Lucca wrote in the 13th-century: “Every day we see new instruments and new methods [to extract arrows] being invented by clever and ingenious surgeons.” If you did not know Theodoric of Lucca, or to give him his proper name Theodoric Borgognoni (1205 – 1296/8) [3], was an Italian who became one of the most significant surgeons of the mediæval period. A Dominican friar and Bishop of Cervia, Borgognoni is considered responsible for introducing and promoting important medical advances including basic antiseptic practice in surgery and the use of anaesthetics. By the 14th-century, prominent surgeon Guy de Chauliac wrote about inhalational anaesthesia, medicaments that send the patients to sleep made of opium, juice of the morel, Hyoscyamus, mandrake, ivy, hemlock and lettuce. The practise was to soak a fresh sponge with these juices before drying it in the sun. When needed the sponge would be placed in warm water to activate the anaesthetic properties and then held under the nostrils of the patent until they fell asleep.

Another 14th-century surgeon, Henri de Mondeville (c. 1260 – 1316), served two French kings, namely Philip IV and Louis X. More importantly, in 1312 he wrote his treatise on surgery entitled “Cyrurgia” based on his years of training in both France and Italy. His work reveals a wide scope of mediæval medical treatments ranging from removing arrows to dealing with rabid dog bites and advice on how to perform amputations.

As to the removal of barbed arrowheads, of prime importance is knowing just what kind of arrow you are dealing with. There are different techniques for each, and various instruments accordingly. If the surgeon lacks that information he frequently be misled … as once happened to me … in a case when an arrow had entered the forearm near the wrist and had passed beneath the soft tissues along the surface of the bone, directed toward the elbow. It went under the outer cord which moves the hand. As I tried to pull it out through the wound of entry I failed to recognize that it had small barbs – it was an English arrow – which had caught the muscle and I could neither unhook it nor extract the arrow. I had to make an incision over the point to remove the metal piece, having to enlarge the wound in the process, much to the great distress of the victim as well as of me.

Henri de Mondeville, “Cyrurgia”

Hospitals While often been portrayed as an era of ignorant physicians and of health care based on superstition and quackery, a closer look reveals that there were many ways in which medical knowledge and healthcare improved during the Mediæval period. Hospitals, for example, had early antecedents. The Romans had no public hospitals as we would recognise them, but medical facilities - principally military valetudinaria and religious healing temples - did provide care for soldiers, slaves, and the sick. By the 4th-century AD the concept of a hospital – a place where patients could be treated by doctors with access to specialised equipment – was emerging in parts of the Roman Empire. The earliest mediæval hospitals originated in Christian religious establishments to provide lodgings and care for the poor and travellers. In Byzantium (the Eastern Roman Empire) and western Europe, for example, hospitals were usually run by monasteries. Over time they would gradually become larger and more complex. Meanwhile, in the Arabic world hospitals emerged a little later in the 9th-century as more secular institutions. In larger cities they could be staffed by dozens of physicians, having several wards for different illnesses, and could even have amenities like musicians playing in the halls.

Pharmacies The first pharmacy was established in Baghdad in AD 754. One medieval Arabic physician explained these places were for “the art of knowing the materia medica samples in their various species, types and shapes. From these, the pharmacist prepares compounded medications as prescribed and ordered by the prescribing physician.” Proving to be very popular, ever more pharmacies opened across the Arabic world until, by the 12th-century, they could be found in Europe. Such pharmacies greatly aided our understanding of drugs and allowed more people to access their benefits.

Ophthalmology The practice of ophthalmology has been documented since ancient times. Its existence can be traced back to Ancient Babylon with a reference to the eyes made in the Code of Hammurabi (2250 BC): “If a physician performs eye surgery and saves the eye, he shall receive ten shekels in money.” However, it was not until Ancient Egypt when the discovery of the Ebers Papyrus, a 110-page scroll dating to ca. 1550 BC, gives us the first written record of medical treatments for eye disease. A millennia later and the prominent Greek philosopher-physician Alcmaeon of Croton (540-500 BC) is widely regarded as the first to examine and describe the human eye. Building on this pioneering work, a collection of approximately 60 early Ancient Greek medical works by Hippocrates (460-375 BC) known as the Hippocratic Corpus further advanced Alcmaeon’s ideas.

By the time of the Romans, ophthalmology had further progressed and modified pre-existing classical Greek knowledge. Greco-Roman physicians made remarkable anatomical discoveries about the eye and refined surgical instruments and techniques. Among these, Celsus (25 BC to 50 AD) was the first to systematically deal with ophthalmology in his encyclopaedic work De Re Medica. Celsus described various ocular diseases and their treatment. His belief that the crystalline lens was the organ which received visual information before converting it into a different form persisted through the Middle Ages.

The field of ophthalmology was revolutionised by the medieval Arab scholar Ibn Al-Haytham (ca. 965 to ca. 1040) through his Book of Optics (كتاب المناظر, Kitab al-Manazir), a seven-volume treatise on optics and other fields of study. Known in the West as Alhazen or Alhacen, Ibn Al-Haytham presented experimentally founded arguments against the widely held extramission theory of vision. As understood, for example by Euclid in his Optica, this conceived that visual perception was accomplished by eye beams emitted by the eyes. Al-Haytham’s work, however, was the first to propose the modern intromission theory, the now accepted model that vision takes place by light entering the eye. The Book of Optics is also noted for its early use of the scientific method, its description of the camera obscura, and its formulation of Al-Haytham’s problem. The book extensively affected the development of optics, physics and mathematics in Europe between the 13th- and 17th-centuries.

Spectacles The classical Roman writer Seneca is said to have read all the books in Rome by using a glass globe of water to enlarge the handwritten letters. Strictly speaking he was using a form of magnifying glass, but anything held to the eye and not worn on the face are categorised as “eyeglasses” not spectacles. The idea of wearing spectacles on the face for lengthy periods seems to have been a mediæval European invention. By the end of the 13th-century, however, spectacles designed to help correct vision were apparently well-known in Italy:

“It is not yet twenty years since there was found the art of making eyeglasses, which make for good vision…And it is so short a time that this new art, never before extant, was discovered…I saw the one who first discovered and practiced it, and I talked to him.”

Dominican friar Giordano da Pisa, 1305

The earliest depiction of a person wearing spectacles was in 1352 when Tommaso da Modena included an image of Cardinal Hugh of Provence as part of a fresco in a church. It shows the cardinal wearing the glasses as he writes at his desk (above right).

Anatomy and dissection Many historians have believed that knowledge about anatomy stagnated during the Middle Ages. There is, however, a great deal of evidence that medieval physicians were conducting experiments and examining the anatomy of the human body. In AD 1315 the Italian physician Mondino de Luzzi even conducted a public dissection for his students and spectators. The following year he would write Anathomia corporis humani considered the first example of a modern dissection manual and the first true anatomical text.

Caesarean sections While caesarean sections had been practiced from Roman times, they were only performed to deliver a child in the full knowledge that either a pregnant mother had just died or had no chance of survival. Advances in mediæval anatomical knowledge led to the survival of both a mother and baby around AD 1500. In the first written record of surviving a caesarean section, a Swiss farmer named Jacob Nufer performed the operation on his wife. She had been in labour for several days and was being assisted by thirteen midwives but was still unable to deliver her baby. The operation was a success, with the mother subsequently going on to give birth to five more children, including twins. The baby lived to be 77 years old.

Cleaning wounds Whether the patient survived such surgeries relied heavily on infection control in a world for whom microbiology was a distant horizon. Many ancient medical writers believed that during surgery some pus should remain in wounds in the belief that this would aid healing. This idea remained widespread until the aforementioned 13th-century surgeon Theodoric Borgognoni established an antiseptic method where wounds were to be cleaned and then sutured to promote healing. Even during surgical procedures this innovative Italian surgeon was known to have bandages pre-soaked in wine as a form of disinfectant. As already mentioned, Theodoric was also known for pioneering the use of anaesthetics in surgery.

Quarantine The COVID-19 pandemic introduced to a hitherto unwitting worldwide audience the concept of quarantine and keeping groups of people apart to combat the disease’s spread. The word “quarantine” has its roots in the period of European history known as the Black Death [4], though the practice of isolating people to prevent the spread of disease is older. In the city-state of Ragusa (modern Dubrovnik, Croatia), implemented an isolation period in 1377 for new arrivals to the city’s port from plague-affected areas. Arriving ships had to wait 30 days in the harbour before docking so that authorities could be sure no one was infected. The isolation period of thirty days was later extended to forty days and given the name “quarantino” from the Italian word quaranta meaning “forty”. The success of these measures led to them being used in other parts of Italy and across Europe by the end of the Middle Ages.

Medical education in universities All of these advances in medical knowledge and the gradual changes to the practises of medicine were aided by the rise of universities throughout Mediæval Europe. Many of these institutions would teach physicians and become the main centres through which medical knowledge would be shared. As early as AD 1231, the Holy Roman Emperor, Frederick II, promulgated a set of laws (the Liber Augustalis or Constitutions of Melfi) that made medicine a state‑regulated profession, set formal training requirements, and established public health standards. Before Frederick II, medical care in Mediæval Europe had been largely unregulated, provided by monastic healers, wandering practitioners, and apothecaries without oversight. Frederick’s reforms, enacted in his kingdom of Sicily, were unprecedented in placing medicine under royal authority rather than guilds or religious institutions. The key provisions were:

• The licensing of physicians. No one could practice medicine without first passing a public examination at the University of Salerno by a licensed professor. Successful candidates received a certificate from both the professor and a royal official.

• Training required at least three years in logic (one of the foundations of the liberal arts) before medical study, followed by five years of medical training in anatomy, dietetics, surgery, and pharmacology.

Although these laws did not have an immediate effect, Frederick II’s codification ensured a developing educational method would become a cornerstone in the professionalisation of physicians. Moreover, such foresight surely disproves any notion that mediæval medical knowledge was one of ignorance, superstition and quackery. Instead, one might argue that modern hospitals, pharmacies, anatomy, surgery, spectacles, and even the concept of quarantine owe much to Mediæval pioneers. Bon appétit!

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Endnotes:

1. Francis Petrarch, born Francesco di Petracco on 20 July 1304 (died 19 July 1374), was a scholar from Arezzo and poet of the early Italian Renaissance. One of the earliest humanists, he is also known for being the first to develop the concept of the “Dark Ages”. ▲

2. Galen was born in September AD 129 in Pergamum, Mysia, Anatolia [now Bergama, Türkiye] and died c. AD 216). ▲

3. Also known as Teodorico de’ Borgognoni. His major contribution to western medicine was “The Cyrurgia”, or Chirurgia, (Surgery). Written in the mid-13th-century, it is a four volume work that covers the major fields of medieval surgery. ▲

4. The Black Death was a plague pandemic that occurred in Europe from 1346 to 1353. It was one of the most fatal pandemics in human history, leading to the death of up to 50 million people, around 30% to 60% of the European population and approximately 33% of the Middle Eastern population. The disease was caused by the bacterium Yersinia pestis, which is primarily spread by flea bites, though it may also spread through contact with infected tissues or fluids and, in pneumonic cases, through respiratory droplets. ▲