Medieval medicine of Western Europe

In the Middle Ages, the medicine of Western Europe was composed of a mixture of existing ideas from antiquity. In the Early Middle Ages, following the fall of the Western Roman Empire, standard medical knowledge was based chiefly upon surviving Greek and Roman texts, preserved in monasteries and elsewhere. Medieval medicine is widely misunderstood, thought of as a uniform attitude composed of placing hopes in the church and God to heal all sicknesses, while sickness itself exists as a product of destiny, sin, and astral influences as physical causes. On the other hand, medieval medicine, especially in the second half of the medieval period (c. 1100–1500 AD), became a formal body of theoretical knowledge and was institutionalized in the universities. Medieval medicine attributed illnesses, and disease, not to sinful behavior, but to natural causes, and sin was connected to illness only in a more general sense of the view that disease manifested in humanity as a result of its fallen state from God. Medieval medicine also recognized that illnesses spread from person to person, that certain lifestyles may cause ill health, and some people have a greater predisposition towards bad health than others.^[1]

Influences

Hippocratic medicine

The Western medical tradition often traces its roots directly to the

Folk medicine of the Middle Ages dealt with the use of herbal remedies for ailments. The practice of keeping physic gardens teeming with various herbs with medicinal properties was influenced by the gardens of Roman antiquity.^[11] Many early medieval manuscripts have been noted for containing practical descriptions for the use of herbal remedies. These texts, such as the Pseudo-Apuleius, included illustrations of various plants that would have been easily identifiable and familiar to Europeans at the time.^[11] Monasteries later became centers of medical practice in the Middle Ages, and carried on the tradition of maintaining medicinal gardens. These gardens became specialized and capable of maintaining plants from the Southern Hemisphere as well as maintaining plants during winter.^[11]

Hildegard of Bingen was an example of a medieval medical practitioner who, while educated in classical Greek medicine, also utilized folk medicine remedies.^[13] Her understanding of the plant based medicines informed her commentary on the humors of the body and the remedies she described in her medical text Causae et curae were influenced by her familiarity with folk treatments of disease. In the rural society of Hildegard's time, much of the medical care was provided by women, along with their other domestic duties.^{[citation needed]} Kitchens were stocked with herbs and other substances required in folk remedies for many ailments.^[12] Causae et curae illustrated a view of symbiosis of the body and nature, that the understanding of nature could inform medical treatment of the body. However, Hildegard maintained the belief that the root of disease was a compromised relationship between a person and God.^[12] Many parallels between pagan and Christian ideas about disease existed during the early Middle Ages.^{[citation needed]} Christian views of disease differed from those held by pagans because of a fundamental difference in belief: Christians' belief in a personal relationship with God greatly influenced their views on medicine.^[14]

Evidence of pagan influence on emerging Christian medical practice was provided by many prominent early Christian thinkers, such as

A combination of both spiritual and natural healing was used to treat the sick. Herbal remedies, known as

Not only were herbal texts being produced, but also other medieval texts that discussed the importance of the humors. Monasteries in Medieval Europe gained access to Greek medical works by the middle of the 6th century.[17] Monks translated these works into Latin, after which they were gradually disseminated across Europe. Monks such as Arnald of Villanova also translated the works of Galen and other classical Greek scholars from Arabic to Latin during the Middle Ages.^[18] By producing these texts and translating them into Latin, Christian monks both preserved classical Greek medical information and allowed for its use by European medical practitioners. By the early 1300s these translated works would become available at medieval universities and form the foundation of the universities medical teaching programs.^[19]

Hildegard of Bingen, a well known abbess, wrote about Hippocratic Medicine using humoral theory and how balance and imbalance of the elements affected the health of an individual, along with other known sicknesses of the time, and ways in which to combine both prayer and herbs to help the individual become well. She discusses different symptoms that were common to see and the known remedies for them.^[20]

In exchanging the herbal texts among monasteries, monks became aware of herbs that could be very useful but were not found in the surrounding area. The monastic clergy traded with one another or used commercial means to obtain the foreign herbs.

Medicine in the monasteries was concentrated on assisting the individual to return to normal health. Being able to identify symptoms and remedies was the primary focus. In some instances identifying the symptoms led the monastic clergy to have to take into consideration the cause of the illness in order to implement a solution. Research and experimental processes were continuously being implemented in monasteries to be able to successfully fulfill their duties to God to take care of all God's people.

Christian charity

Christian practice and attitudes toward medicine drew on Middle Eastern (particularly from local

Charity, the driving principle behind these healing centers, encouraged the early Christians to care for others. The cities of Jerusalem, Constantinople, and Antioch contained some of the earliest and most complex hospitals, with many beds to house patients and staff physicians with emerging specialties.^[25] Some hospitals were large enough to provide education in medicine, surgery and patient care. St. Basil (AD 330–79) argued that God put medicines on the Earth for human use, while many early church fathers agreed that Hippocratic medicine could be used to treat the sick and satisfy the charitable need to help others.^[26]

Medicine

Medieval European medicine became more developed during the

At

In the mid-fourteenth century, there were restrictions placed on London surgeons as to what types of injuries they were able to treat and the types of medications that they could prescribe or use, because surgery was still looked at as an incredibly dangerous procedure that should only be used appropriately. Some of the wounds that were allowed to be performed on were external injuries, such as skin lacerations caused by a sharp edge, such as by a sword, dagger and axe or through household tools such as knives. During this time, it was also expected that the surgeons were extremely knowledgeable on human anatomy and would be held accountable for any consequences as a result of the procedure.^[34]

Advances

The Middle Ages contributed a great deal to medical knowledge. This period contained progress in surgery, medical chemistry, dissection, and practical medicine. The Middle Ages laid the ground work for later, more significant discoveries. There was a slow but constant progression in the way that medicine was studied and practiced. It went from apprenticeships to universities and from oral traditions to documenting texts. The most well-known preservers of texts, not only medical, would be the monasteries. The monks were able to copy and revise any medical texts that they were able to obtain.

Besides documentation the Middle Ages also had one of the first well known female physicians, Hildegard of Bingen. Hildegard was born in 1098 and at the age of fourteen she entered the double monastery of Dissibodenberg.^[35] She wrote the medical text Causae et curae, in which many medical practices of the time were demonstrated. This book contained diagnosis, treatment, and prognosis of many different diseases and illnesses. This text sheds light on medieval medical practices of the time. It also demonstrates the vast amount of knowledge and influences that she built upon. In this time period medicine was taken very seriously, as is shown with Hildegard's detailed descriptions on how to perform medical tasks.^[36] The descriptions are nothing without their practical counterpart, and Hildegard was thought to have been an infirmarian in the monastery where she lived. An infirmarian treated not only other monks but pilgrims, workers, and the poor men, women, and children in the monastery's hospice. Because monasteries were located in rural areas the infirmarian was also responsible for the care of lacerations, fractures, dislocations, and burns.^[37] Along with typical medical practice the text also hints that the youth (such as Hildegard) would have received hands-on training from the previous infirmarian. Beyond routine nursing this also shows that medical remedies from plants, either grown or gathered, had a significant impact of the future of medicine. This was the beginnings of the domestic pharmacy.^[38]

Although plants were the main source of medieval remedies, around the sixteenth century medical

The Middle Ages brought a new way of thinking and a lessening on the taboo of dissection. Dissection for medical purposes became more prominent around 1299.[42] During this time the Italians were practicing anatomical dissection and the first record of an autopsy dates from 1286. Dissection was first introduced in the educational setting at the university of Bologna, to study and teach anatomy. The fourteenth century saw a significant spread of dissection and autopsy in Italy, and was not only taken up by medical faculties, but by colleges for physicians and surgeons.^[43]

Compendiums like Bald's Leechbook (circa 900), include citations from a variety of classical works alongside local folk remedies.

Theories of medicine

Although each of these theories has distinct roots in different cultural and religious traditions, they were all intertwined in the general understanding and practice of medicine. For example, the Benedictine abbess and healer, Hildegard of Bingen, claimed that

The theory of

The astrological signs of the zodiac were also thought to be associated with certain humours . Even now, some still use words "choleric", "sanguine", "phlegmatic" and "melancholic" to describe personalities.

Herbalism and botany

Herbs were commonly used in salves and drinks to treat a range of maladies. The particular herbs used depended largely on the local culture and often had roots in pre-Christian religion.^[45] The success of herbal remedies was often ascribed to their action upon the humours within the body. The use of herbs also drew upon the medieval Christian doctrine of signatures which stated that God had provided some form of alleviation for every ill, and that these things, be they animal, vegetable or mineral, carried a mark or a signature upon them that gave an indication of their usefulness. For example, skullcap seeds (used as a headache remedy) can appear to look like miniature skulls; and the white spotted leaves of lungwort (used for tuberculosis) bear a similarity to the lungs of a diseased patient. A large number of such resemblances were believed to exist.

Many monasteries developed herb gardens for use in the production of herbal cures,^[47] and these remained a part of folk medicine, as well as being used by some professional physicians. Books of herbal remedies were produced, one of the most famous being the Welsh, Red Book of Hergest, dating from around 1400.

During the early Middle Ages, botany had undergone drastic changes from that of its antiquity predecessor (Greek practice). An early medieval treatise in the West on plants known as the Ex herbis femininis was largely based on Dioscorides Greek text: De material medica. The Ex herbis was a lot more popular during this time because it was not only easier to read, but contained plants and their remedies that related to the regions of southern Europe, where botany was being studied. It also provided better medical direction on how to create remedies, and how to properly use them. This book was also highly illustrated, where its former was not, making the practice of botany easier to comprehend.^[48]

The re-emergence of Botany in the medieval world came about during the sixteenth century. As part of the revival of classical medicine, one of the biggest areas of interest was materia medica: the study of remedial substances. “Italian humanists in the fifteenth century had recovered and translated ancient Greek botanical texts which had been unknown in the West in the Middle Ages or relatively ignored”.^[49] Soon after the rise in interest in botany, universities such as Padua and Bologna started to create programs and fields of study; some of these practices including setting up gardens so that students were able to collect and examine plants. “Botany was also a field in which printing made a tremendous impact, through the development of naturalistic illustrated herbals”.^[49] During this time period, university practices were highly concerned with the philosophical matters of study in sciences and the liberal arts, “but by the sixteenth century both scholastic discussion of plants and reliance upon intermediary compendia for plant names and descriptions were increasingly abandoned in favor of direct study of the original texts of classical authors and efforts to reconcile names, descriptions, and plants in nature”.^[50] Botanist expanded their knowledge of different plant remedies, seeds, bulbs, uses of dried and living plants through continuous interchange made possible by printing. In sixteenth century medicine, botany was rapidly becoming a lively and fast-moving discipline that held wide universal appeal in the world of doctors, philosophers, and pharmacists.^[51]

Mental disorders

Those with

Medicine in the Middle Ages was rooted in Christianity through not only the spread of medical texts through monastic tradition but also through the beliefs of sickness in conjunction with medical treatment and theory. Christianity, throughout the medieval period, did not set medical knowledge back or forwards.^[56] The church taught that God sometimes sent illness as a punishment, and that in these cases, repentance could lead to a recovery. This led to the practice of penance and pilgrimage as a means of curing illness. In the Middle Ages, some people did not consider medicine a profession suitable for Christians, as disease was often considered God-sent. God was considered to be the "divine physician" who sent illness or healing depending on his will. From a Christian perspective, disease could be seen either as a punishment from God or as an affliction of demons (or elves, see first paragraph under Theories of Medicine). The ultimate healer in this interpretation is of course God, but medical practitioners cited both the bible and Christian history as evidence that humans could and should attempt to cure diseases. For example, the Lorsch Book of Remedies or the Lorsch Leechbook contains a lengthy defense of medical practice from a Christian perspective. Christian treatments focused on the power of prayer and holy words, as well as liturgical practice.^[57]

However, many monastic orders, particularly the

Hildegard of Bingen (1098–1179) played an important role in how illness was interpreted through both God and natural causes through her medical texts as well. As a nun, she believed in the power of God and prayer to heal, however she also recognized that there were natural forms of healing through the humors as well. Though there were cures for illness outside of prayer, ultimately the patient was in the hands of God.^[62] One specific example of this comes from her text Causae et Curae in which she explains the practice of bleeding:

Bleeding, says Hildegard, should be done when the moon is waning, because then the "blood is low" (77:23–25). Men should be bled from the age of twelve (120:32) to eighty (121:9), but women, because they have more of the detrimental humors, up to the age of one hundred (121:24). For therapeutic bleeding, use the veins nearest the diseased part (122:19); for preventive bleeding, use the large veins in the arms (121:35–122:11), because they are like great rivers whose tributaries irrigate the body (123:6–9, 17–20). 24 From a strong man, take "the amount that a thirsty person can swallow in one gulp" (119:20); from a weak one, "the amount that an egg of moderate size can hold" (119:22–23). Afterward, let the patient rest for three days and give him undiluted wine (125:30), because "wine is the blood of the earth" (141:26). This blood can be used for prognosis; for instance, "if the blood comes out turbid like a man's breath, and if there are black spots in it, and if there is a waxy layer around it, then the patient will die, unless God restore him to life" (124:20–24).^[62]

The medieval medical universities' central concept concentrated on the balance between the humors and "in the substances used for therapeutic purposes".[71] The curriculum's secondary concept focused on medical astrology, where celestial events were thought to influence health and disease.^[71] The medical curriculum was designed to train practitioners.^[72] Teachers of medical students were often successful physicians, practicing in conjunction with teaching. The curriculum of academic medicine was fundamentally based on translated texts and treatises attributed to Hippocrates and Galen as well as Arabic medical texts.^[73] At Montpellier's Faculty of Medicine professors were required in 1309 to possess Galen's books which described humors, De complexionibus, De virtutibus naturalibus, De criticis diebu so that they could teach students about Galen's medical theory.^[74] The translated works of Hippocrates and Galen were often incomplete, and were mediated with Arabic medical texts for their "independent contributions to treatment and to herbal pharmacology".^[75] Although anatomy was taught in academic medicine through the dissection of cadavers, surgery was largely independent from medical universities.^[76] The University of Bologna was the only university to grant degrees in surgery. Academic medicine also focused on actual medical practice where students would study individual cases and observe the professor visiting patients.^[72]

The required number of years to become a licensed physician varied among universities. Montpellier required students without their masters of arts to complete three and a half years of formal study and six months of outside medical practice.^[77][78] In 1309, the curriculum of Montpellier was changed to six years of study and eight months of outside medical practice for those without a masters of arts, whereas those with a masters of arts were only subjected to five years of study with eight months of outside medical practice.^[78] The university of Bologna required three years of philosophy, three years of astrology, and four years of attending medical lectures.^[78]

Medical practitioners

Members of

There were many other medical practitioners besides clergy. Academically trained doctors were particularly important in cities with universities. Medical faculty at universities figured prominently in defining medical guilds and accepted practices as well as the required qualifications for physicians.^[47] Beneath these university-educated physicians there existed a whole hierarchy of practitioners. Wallis^{[citation needed]} suggests a social hierarchy with these university educated physicians on top, followed by "learned surgeons; craft-trained surgeons; barber surgeons, who combined bloodletting with the removal of "superfluities" from the skin and head; itinerant specialist such as dentist and oculists; empirics; midwives; clergy who dispensed charitable advice and help; and, finally, ordinary family and neighbors".^[47] Each of these groups practiced medicine in their own capacity and contributed to the overall culture of medicine.

Hospital system

In the Medieval period the term hospital encompassed hostels for travellers, dispensaries for poor relief, clinics and surgeries for the injured, and homes for the blind, lame, elderly, and mentally ill. Monastic hospitals developed many treatments, both therapeutic and spiritual.

During the thirteenth century an immense number of hospitals were built. The Italian cities were the leaders of the movement. Milan had no fewer than a dozen hospitals and Florence before the end of the fourteenth century had some thirty hospitals. Some of these were very beautiful buildings. At Milan a portion of the general hospital was designed by Bramante and another part of it by Michelangelo. The Hospital in Sienna, built in honor of St. Catherine, has been famous ever since. Everywhere throughout Europe this hospital movement spread. Virchow, the great German pathologist, in an article on hospitals, showed that every city of Germany of five thousand inhabitants had its hospital. He traced all of this hospital movement to Pope Innocent III, and though he was least papistically inclined, Virchow did not hesitate to give extremely high praise to this pontiff for all that he had accomplished for the benefit of children and suffering mankind.^[79]

Hospitals began to appear in great numbers in France and England. Following the

Owing to a well-preserved 12th-century account of the monk Eadmer of the Canterbury cathedral, there is an excellent account of Bishop Lanfranc's aim to establish and maintain examples of these early hospitals:

But I must not conclude my work by omitting what he did for the poor outside the walls of the city Canterbury. In brief, he constructed a decent and ample house of stone…for different needs and conveniences. He divided the main building into two, appointing one part for men oppressed by various kinds of infirmities and the other for women in a bad state of health. He also made arrangements for their clothing and daily food, appointing ministers and guardians to take all measures so that nothing should be lacking for them.^[81]

Later developments

High medieval surgeons like

During the period of the Renaissance from the mid 1450s onward, there were many advances in medical practice. The Italian Girolamo Fracastoro (1478–1553) was the first to propose that epidemic diseases might be caused by objects outside the body that could be transmitted by direct or indirect contact.^[82] He also proposed new treatments for diseases such as syphilis.

In 1543 the Flemish Scholar

During the 16th century,

The French army doctor

In Medieval Europe the surgeon's social status improved greatly as their expertise was needed on the battlefield.^[88] Owing to the number of patients, warfare created a unique learning environment for these surgeons. The dead bodies also provided an opportunity for learning. The corpses provided a means to learn through hands on experience. As war declined, the need for surgeons declined as well. This would follow a pattern, where the status of the surgeon would flux in regards to whether or not there was actively a war going on.^[88]

First medical schools

Medical school also first appeared in the Medieval period. This created a divide between physicians trained in the classroom and physicians who learned their trade through practice. The divide created a shift leading to physicians trained in the classroom to be of higher esteem and more knowledgeable. Despite this, there was still a lack of knowledge by physicians in the militaries.^[89] The knowledge of the militaries' physicians was greatly acquired through first hand experience. In the Medical schools, physicians such as Galen were referenced as the ultimate source of knowledge. Thus, the education in the schools was aimed at proving these ancient physicians were correct. This created issues as Medieval knowledge surpassed the knowledge of these ancient physicians. In the scholastic setting it still became practice to reference ancient physicians or the other information being presented was not taken seriously.^[90]

Level of care

The soldiers that received medical attention was most likely from a physician who was not well trained. To add to this, a soldier did not have a good chance of surviving a wound that needed specific, specialized, or knowledgeable treatment.^[89] Surgery was oftentimes performed by a surgeon who knew it as a craft. There were a handful of surgeons such as Henry de Mondeville, who were very proficient and were employed by Kings such as King Phillip. However; this was not always enough to save kings’ lives, as King Richard I of England died of wounds at the siege of Chalus in AD 1199 due to an unskilled arrow extraction.^[89]

Wound treatment

Arrow extraction

Treating a wound was and remains the most crucial part of any battlefield medicine, as this is what keeps soldiers alive. As remains true on the modern battlefield, hemorrhaging and shock were the number one killers. Thus, the initial control of these two things were of the utmost importance in medieval medicine.^[89] Items such as the long bow were used widely throughout the medieval period, thus making arrow extracting a common practice among the armies of Medieval Europe. When extracting an arrow, there were three guidelines that were to be followed. The physicians should first examine the position of the arrow and the degree to which its parts are visible, the possibility of it being poisoned, the location of the wound, and the possibility of contamination with dirt and other debris. The second rule was to extract it delicately and swiftly. The third rule was to stop the flow of blood from the wound.^[89]

The arrowheads that were used against troops were typically not barbed or hooked, but were slim and designed to penetrate armor such as

Another common injury faced was those caused by blades. If the wound was too advanced for simple stitch and bandage, it would often result in amputation of the limb. Surgeons of the Medieval battlefield had the practice of amputation down to an art. Typically it would have taken less than a minute for a surgeon to remove the damaged limb, and another three to four minutes to stop the bleeding.^[92] The surgeon would first place the limb on a block of wood and tie ligatures above and below the site of surgery. Then the soft tissue would be cut through, thus exposing the bone, which was then sawed through. The stump was then bandaged and left to heal. The rates of mortality among amputation patients was around 39%, that number grew to roughly 62% for those patients with a high leg amputation.^[92] Ideas of medieval surgery are often construed in modern minds as barbaric, as our view is diluted with our own medical knowledge. Surgery and medical practice in general was at its height of advancement for its time. All procedures were done with the intent to save lives, not to cause extra pain and suffering. The speed of the procedure by the surgeon was an important factor, as the limit of pain and blood loss lead to higher survival rates among these procedures.^[92]

Injuries to major arteries that caused mass blood loss were not usually treatable as shown in the evidence of archeological remains.^[91] We^[who?] know this as wounds severe enough to sever major arteries left incisions on the bone which is excavated by archaeologists. Wounds were also taught to be covered to improve healing. Forms of antiseptics were also used in order to stave off infection. To dress wounds all sorts of dressing were used such as grease, absorbent dressings, spider webs, honey, ground shellfish, clay and turpentine. Some of these methods date back to Roman battlefield medicine.^[93]

Bone breakage

Sieges were a dangerous place to be, as broken bones became an issue, with soldiers falling while they scaled the wall amongst other methods of breakage. Typically, it was long bones that were fractured. These fractures were manipulated to get the bones back into their correct location.^[92] Once they were in their correct location, the wound was immobilized by either a splint or a plaster mold. The plaster mold (an early cast) was made of flour and egg whites and was applied to the injured area. Both of these methods left the bone immobilized and gave it a chance to heal.^[92]

Burn treatment

Burn treatment also required a specific approach by physicians of the time. This was due to burning oil and arrows or boiling water, which were used in combat. In the early stages of treatment there was an attempt to stop the formation of blisters. The burn was prevented from becoming dry by using anointments placed on the burn. These anointments typically consisted of vinegar, egg, rose oil, opium, and a multitude of different herbs.^[92] The ointment was applied to affected area, and then reapplied as needed.

See also

• Byzantine medicine
• Cucupha
• History of hospitals
• History of medicine
• History of nursing
• Ibn Sina Academy of Medieval Medicine and Sciences
• Irish medical families
• Life expectancy
• Medicine in the medieval Islamic world
• Medieval demography
• Plague doctor
• Plague doctor contract
• Plague doctor costume
• Tacuinum Sanitatis
• Theriac
• Timeline of medicine and medical technology
• Treatise on Herbs

Footnotes