The Middle Ages

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 dislocations. 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 revolutionary 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 pestilence, 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 profession, 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 objective, 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 practice of medicine. Setting aside major theological concerns regarding body and soul, it could be argued that medicine was an art, like agriculture, 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 hardworking 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 independent 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 operations. 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 mortification 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 ultimately 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 dismembered 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 physicians 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 operation 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 transformed into churches where the worship of Christ the Healer, or his healing saints, provided a familiar setting for medical miracles. In contrast 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 indicates 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 compilations in the monasteries reflect interest in logic and philology rather than science, but there is evidence that medical manuscripts were consulted 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 dialogue—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 useful 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 periods. 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 apparently 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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