It’s tempting to see medieval doctors as a group of quacks and inadequates stuck between the Dark Ages and the enlightened Renaissance. Certainly, it was a dangerous time to be alive and sick. In the twelfth century the majority of people lived in rural servitude and received no education. Average life expectancy was 30-35 years with 1 in 5 children dying at birth. Healthcare policy, such as it was, was based on Christian teachings; that it was everyone’s duty to care for the sick and poor. To that end medieval hospitals more resembled modern day hospices providing basic care for the destitute and dying with nowhere else to go. Education and literacy were largely the preserve of the clergy and it was in monasteries where most hospitals could be found. The Saxons built the first hospital in England in 937 C. E, and many more followed after the Norman Conquest in 1066, including St. Bartholomew's of London, built in 1123 C.E. The sick were cared for by a mix of practitioners including physicians, surgeons, barber-surgeons and apothecaries. Of these only physicians would have received formal training. The vast majority of people providing healthcare were practising a mix of folklore and superstition.
However, it was in the early medieval period that the first medical schools were formed and the first ever medical students went to university. In this musing I’m looking at what medical education was like in the Middle Ages at the most prestigious university of the age as well as the common theories behind disease and cure.
The Schola Medica Salernitana was founded in the 9th century in the Southern Italian city of Salerno. In 1050 one of its teachers Gariopontus wrote the Passionarius, one of the earliest written records of Western Medicine as we would recognise it. Gariopontus drew on the teachings of Galen (c. 129-199 CE) and latinised Greek terms. In doing so he formed the basis of several modern medical terms such as cauterise. Another early writing mentioned a student: “ut ferrum magnes, juvenes sic attrahit Agnes” (Agnes attracts the boys like iron to a magnet”). This shows that the first medical school in the world had female students.
The medical school published a number of treatises such as work by a woman called Trotula on childbirth and uterine prolapse and work on the management of cranial and abdominal wounds. In head wounds it was recommended to feel for and then surgical remove pieces of damaged skull. In abdominal trauma students were advised to try to put any protruding intestine back inside the abdomen. If the intestine was cold it was to be warmed by wrapping the intestines of a freshly killed animal over it beforehand with the wound being left open before a drain was inserted.
Anatomy remained based on the work of Galen. Doctors were encouraged to dissect pigs as their anatomy was felt to be the most closely related to humans. However, the teachers were more innovative when it came to disseminating knowledge, in verse form often with a spice of humour. 362 of these verses were printed for the first time in 1480 and would increase to 3520 verses in a later edition. By 1224 the Holy Roman Emperor Frederick II made it obligatory that anyone hoping to practice Medicine in the kingdom of Naples should seek approval from the masters of Salerno medical school.
But Salerno medical school did not teach any other subjects and so did not evolve into a studium generale or university as they began to spring up. By the fourteenth century the most prestigious medical school in Europe was the University of Bologna, founded in 1088, the oldest university in the world. In the United Kingdom medical training began at the University of Oxford in the 12th century but was haphazard and based on apprenticeship. The first formal UK medical school would not be established until 1726 in Edinburgh.
The University of Bologna was run along democratic lines, with students choosing their own professors and electing a rector who had precedence over everyone, including cardinals, at official functions.
The Medicine course lasted 4 years and consisted of forty six lectures. Each lecture focused on one particular medical text as written by Hippocrates (c. 460-370 BCE), Galen, and Avicenna (c. 980-1037 CE). Students would also read texts by these authors and analyse them using the methods of the French philosopher Peter Abelard to draw conclusions. His work Sic et Non had actually been written as guide for debating contrasting religious text, not scientific work. This reflected how religion and philosophy dominated the training of medical students. The university was attached to a cathedral and students were required to be admitted to the clergy prior to starting their studies. Further to studying Medicine students were also required to study the seven classical liberal arts: Grammar, Rhetoric, Logic, Geometry, Arithmetic, Music and Astronomy.
At the time knowledge of physiology and disease focused on the four humors: phlegm, blood, black bile, and yellow bile. Imbalance of one was what caused disease, for example too much phlegm caused lung disease and the body had to cough it up. This was a theory largely unchanged since its inception by the ancient Egyptians. This is why blood letting and purging were often the basis of medieval medicine. The state of imbalance was called dyskrasia while the perfect state of equilibrium was called eukrasia. Disease was also linked to extremes of temperature and personality. For example, patients who were prone to anger or passion were at risk of overheating and becoming unwell. Patients would also be at risk if they went to hot or cold places and so doctors were taught to advise maintaining a moderate personalty and avoiding extreme temperatures.
Diet was taught as important to prevent disease. During blood letting doctors were taught to strengthen the patient’s heart through a diet of rose syrup, bugloss or borage juice, the bone of a stag’s heart, or sugar mixed with precious stones such as emerald. Other foods such as lettuce and wine were taught as measures to help balance the humors.
Pharmacy was similarly guided by ancient principles. The Doctrine of Signatures dated back to the days of Galen and was adopted by Christian philosophers and medics. The idea being that in causing disease God would also provide the cure and make that intended cure apparent through design in nature. For example, eyebright flowers were said to resemble the human eye, while skullcap seeds were said to resemble the human skull. This was interpreted as God’s design that eyebright was to be used as a cure for eye disease and skullcap seeds for headaches.
God, the planets and polluted air or miasma were all blamed as the causes of disease. When the Black Death struck Italy in 1347 a contemporary account by the scholar Giovanni Villani blamed “the conjunction of Saturn and Jupiter and Mars in the sign of Aquarius” while the official Gabriel de Mussis noted “the illness was more dangerous during an eclipse, because then its effect was enhanced”. Gentile da Foligno, a physician and professor at the University of Bologna, blamed a tremor felt before the plague hit opening up underground pools of stagnant air and water. Doctors therefore were taught to purify either the body through poultices of mallow, nettles, mercury, and other herbs or the air by breathing through a posy of flowers, herbs and spices. De Mussis mentioned that “doctors attending the sick were advised to stand near an open window, keep their nose in something aromatic, or hold a sponge soaked in vinegar in their mouth.” During the Black Death a vengeful God was often blamed. The flagellants were a group of religious zealots who would march and whip themselves as an act of penance to try and appease God.
There’s a sense here of being close but not quite. Of understanding that balance is important for the body, that environmental factors can cause disease and that there was something unseen spreading disease. Close but not yet there. The Middle Ages isn’t known as a time of enlightenment. That would come with the Renaissance. But it was not a barren wasteland. It was a time of small yet important steps.
It was in the Middle Ages that laws against human dissection were relaxed and knowledge of human anatomy began to improve. An eminent surgeon of the time Guy de Chauliac would lobby for surgeons to require university training and so started to create equivalence with physicians. Physicians began to use more observations to help them diagnose disease, in particular urine as seen in the Fasciculus Medicinae, published in 1491, then the pinnacle of medical knowledge at the time (this book also contained Wound Man as discussed in a previous musing). The scholarly approach encouraged at medical school led to methodical documentation from several physicians; is is through these writings that we know so much about the Black Death and other medieval illness. An English physician Gilbertus Angelicus (1180-1250) teaching at the Montpellier school of Medicine would be one of the first to recognise that diseases such as leprosy and smallpox were contagious.
Perhaps most importantly, it was in this period that the first medical schools and universities were established. These particular small steps would begin the role of doctor as a scholar and start to legislate the standards required of a physician. This would be an vital first step without which future advances could never have been possible.
Thanks for reading