The Medieval Practitioner
By the 1300’s, there were primarily three classes of medical providers. Trained at university and fluent in Latin, the physician was tasked to see patients and advise them on how to get better by consulting the stars and manipulating the four humors (substances in the body). The barber-surgeon was seen as a glorified butcher and performed everything from trimming hair to amputating limbs. The empirics were untrained locals who provided home remedies and specialized services like bone-setting.[1]
A French manuscript detailing how the signs of the zodiac contribute to sickness and healing. [2].
Courtesy of Limbourg brothers. Public Domain.
Medical knowledge came primarily from two sources: the works of Greek physicians Hippocrates and Galen. Hippocrates was a renowned Greek physician who, sometime in the 4th century BCE, wrote a collection of several treatises called The Hippocratic Collection (Corpus Hippocraticum) that were collected by the library of Alexandria in Egypt after his death. The treatises detailed how to set broken bones, diagnose and treat various illnesses, and care for the sick and injured. One of his most famous documents extensively listed diseases associated with each area of the body along with symptoms, treatments, and prognosis (how the disease was likely to progress).[3]
Hippocrates is also credited for his unrivaled medical ethics; though whether or not he wrote it, the Hippocratic oath was named for the physician.[4] The oath states that physicians shall do no harm and, among other things, live an exemplary personal and professional life.[5] These ideas are still the foundation for modern physicians.[6]
The front page of a collection of Hippocrates' works. [7].
Courtesy of Hippocrates, as published by Hieronymus Froben and Nicolaus Episcopius. Public Domain.
Aelius Galenus, anglicized as Galen of Pergamon, was a Greek physician under the Roman Empire in the first century CE. After dissecting many animals, he wrote some of the first and most comprehensive human anatomy books that would form the foundation of medical understanding for the next thousand years. Unfortunately for medical science, Galen was categorically and almost universally wrong. He divided the body into three components; the brain and nerves, responsible for sensation and thought; the heart and arteries, which were what produced energy; and the liver and veins, which made and circulated blood to the rest of the body. This proved seductive in its simplicity and made intuitive sense, leading his ideas to be preserved and spread by Arabic philosophers—and eventually translated into Latin where it would form the foundational understanding of the human body until the early scientific discoveries of the Renaissance dethroned Galen as the father of European medicine.[8]
Galen's "wound man" who shows all the different types of injury and how to treat them. [9].
Courtesy of Wellcome Images. Creative Commons (BY-SA).
Together, Galen and Hippocrates comprised the foundation of medicine as it was understood during the Middle Ages. Medical knowledge was restricted to the clergy, the extremely wealthy, and the well-educated.[10] While cities might be populated with classically-trained physicians and surgeons, rural peoples had difficulty accessing skilled and educated care. This prompted them to seek out local healers who would use folk traditions, practical knowledge, or past experience.
One of Galen's "muscle men.” Notice the incorrect muscle and bone systems—certainly not accurate enough for effective surgery. [11].
Courtesy of Wellcome Images. Creative Commons (BY-SA).
Medieval physicians believed that the stars played a powerful role in sickness and health. They would often carry around an almanac of stars and their signs to advise them on what procedures to perform and when. By the end of the 1500s, physicians across Europe were lawfully required to calculate the position of the moon before carrying out complicated medical procedures, such as surgery or bleeding.[12]
The "zodiac man" who shows the influence of the stars on medical care. [13].
Courtesy of Wellcome Images. Creative Commons (BY-SA).
The Humors
A cornerstone of medieval medicine was the four humors, based on the work of Hippocrates and Galen. This theory claims that the body is comprised of four substances: blood, phlegm, yellow bile, and black bile. Additionally, they were subjected to four states: hot, cold, wet, and dry. Sickness was believed to occur when these humors were out of balance, tainted, or blocked.[14] There was no way to test this because dissection was not survivable and dissections of dead bodies were strictly forbidden by the church.[15]
It was thought that humors were made from the food that the patient ate—that they would sometimes be made incorrectly and sickness would result. Furthermore, the humors were believed to move, like blood moving similarly to the tides of the ocean; if this movement was blocked, then sickness would result. To assess the humors, the physician examined the patient’s complexion, pulse, and urine, in addition to questioning the patient and their family. If the humors were determined to be affected, the physician first attempted natural, nonmedical treatments. Such treatments could include staying in the sun to warm a cold humor or staying in a cold cellar to cool a hot humor. Alternatively, letting air and light dry out a wet humor or soaking in water to moisten a humor that was too dry. In general, physicians then did what we do now: advise rest, sleep, food, and a positive attitude.[16]
A diagram of the four humors. [17].
Courtesy of Tom Lemmens. Public Domain.
A 14th-century recipe for barley soup. From the Tacuinum of Vienna that reads "Savich or Barley Soup (Savich, id est Pultes Ordei) Nature: Cold and dry in the second degree, temperate when it is toasted. Usefulness: Promotes the flow of bile. Dangers: It generates flatulence. Neutralization of the Dangers: With sugar. Effects: Encourages positive humors. It is good for hot temperaments, for the young, in Summer, and in the warm regions.”.[18].
Courtesy of Unknown Master, From the Tacuinum of Vienna. Public Domain.
If the patient failed to improve and the physician decided that medical treatment was necessary, then various treatments were tried. Cupping was the process of placing a glass cup on the skin then heating it until it drew the skin up and moved fluids under the skin, creating a swollen bulb within the cup. Laxatives were used to purge the body; and various medicines could be prescribed, ranging from simple ginger root to concoctions with ingredient lists over fifty items long.[19]
The most common treatment, however, was bleeding. Bloodletting was popular even before Galen’s time, but after he proclaimed blood to be the dominant humor, bleeding’s use because widespread and very popular.[20] Bleeding was divided into local bloodletting, done with leeches and scratching the surface of the skin, and systemic where a vein was cut and allowed to bleed. Systemic bleeding was usually carried out with a sharp needle called a lancet, or a specialized hooked blade called a fleam; Some physicians had several fleams of varying shapes and sizes in a pocket-knife-like housing.[21]
An example of a set of fleams used for bloodletting [22].
Courtesy of Tomyarbro. Creative Commons (BY-SA).
It was thought that bleeding the patient would allow blood to flow free and unblock humors while also removing any tainted blood.[23]
Cataracts and Hernias
While some medieval surgery was barbaric by today’s standards, other procedures were very sophisticated, considering the tools and knowledge available at the time. This was exemplified by the approach to cataracts and hernias.
Cataracts are blurred vision caused by the proteins in the lens (the part of the eye that allows the admittance of light) clumping together and obscuring vision; it is very common in geriatric patients.[24] Today, cataracts are corrected with laser eye surgery, which removes the affected lens and replaces it with an artificial lens; the surgery is one of the most common and effective operations performed in the United States.[25]
During the Middle Ages, cataracts were corrected by cutting the lens then pushing it deeper into the eye in a technique called couching, allowing light back into the eye.[26] Because the lens also focused incoming light, however, the resulting vision was permanently out of focus. Many patients believed that since they were almost blinded by cataracts, then any sight—even blurry vision—was better than full blindness. The surgery was also considered relatively low risk. The patient was already mostly blind; if the surgery went poorly and they lost the eye, their life wouldn’t be much different. If it went well, they might have their vision partially restored.[27]
A depiction of a surgeon couching a lens to restore sight. [28].
Courtesy of Unknown author. Public Domain.
A hernia is when an organ protrudes through the walls of its surroundings; it most commonly occurs when a loop of intestine pokes through a weakened section of the abdominal wall.[29] This is a medical emergency, as blood flow can become constricted to the organ and causing hypoxia and organ death. In the short term, this risks the loss of the organ and in the long term, exposes the patient to infection and gangrene.[30]
The modern treatment is a simple surgery to relocate the organ, and to seal and reinforce the weakened area.[31] In medieval times, the procedure was designed to create enough scar tissue to prevent the intestine from slipping out again.
Surgeons would start by inverting the patient on a board to allow the loop of intestine to fall back into the abdomen. Next, they would take a heated knife and stab into the abdomen repeatedly until the tip of the knife hit the pelvis. The cauterized skin would scar and prevent the intestine from slipping out, while the cauterization itself would prevent fatal internal bleeding. Alternatively, the surgeon could expose the hernia, then use acid to create the desired scar tissue.[32] The only anesthesia available were opioid poppies whose anesthetic properties were well understood by this point.[33] While the surgery was very dangerous with surgeons rummaging around blindly with a hot knife, it was also very effective—so much so that it continued until the Renaissance's anatomical discoveries made this heavy-handed technique obsolete.[34]
Battlefield Medicine
Competent battlefield medicine, with a real answer for infection, wouldn’t be found until World War II, and even using amputation to curtail infection wasn’t used until German surgeon Wilhelm Fabry would recommend it in the 16th century.[35] Doctors usually worked on a fee-for-service model and moved from job to job, but some cities would hire a physician or surgeon (or both) to look after their population and follow their soldiers in the event of war.[36] One of the earliest examples of this is Hugh of Lucca who, in 1216, was contracted by the city of Bologna and annually paid 600 Bolognese lira to care for the city’s surgical needs.[37]
After battles, soldiers had to get themselves to care. Standardized ambulance and transportation services weren’t invented until the British lost more soldiers to disease than combat in the Crimean War and developed The Hospital Conveyance Corps in May 1854. During the Crusades, surgeons worked in hospitals and provided care to injured soldiers. Common treatments included the extraction of arrows, splint application for broken bones (fractures), wound closure for gashes (lacerations), cauterization of heavy bleeding, and dressing burns.[38] In the Frankish States of the Latin East, there appears to be evidence of planned surgical operations taking place—such as bloodletting, limb amputation for chronic disease, scalp surgery for mental illness, draining excess fluid from the abdomen in ascites, hemorrhoid treatment, draining an abscess, and the trimming of overgrown gum tissue in scurvy.[39]
Battle was very dangerous and often produced wounds that were beyond the care of medieval medicine [40].
Courtesy of Unknown author | Der Stricker - Karl St. Gallen, Stiftsbibliothek, Ms. Vad. 302 II, fol. 35v, 13th century manuscript (ca. 1300). Public Domain.
Trephination is the practice of drilling a small hole in the top of the skull that has been practiced since Neolithic times. Though the exact reason why it was performed is unclear, theories range from releasing evil spirits to using the resulting bone disks as charms.[41] In medieval times it was used to relieve intracranial pressure caused by bleeding or swelling in the brain caused by head injuries. The practice was widespread across Europe and eminently survivable, as evidenced by post-surgery skulls with evidence of bone regrowth.[42]
An engraving of a Trepanation in 1525. [43].
Courtesy of Peter Treveris. Public Domain.
A famous example of post-battlefield surgery is the work of John Bradmore. After future King Henry V was struck in the face with an arrow during the Battle of Shrewsbury in 1403, other physicians attempted to remove the arrow and were able to extract the shaft, but the arrowhead remained buried six inches deep to the right of the prince’s nose. First, Bradmore enlarged the hole with probes, then inserted tongs with a screw at the center to expand them. Securing it to the arrowhead, he gently extracted the head. [44] [45].
The prince recovered under Bradmore’s care and didn’t develop seizures or mental lameness, despite the physician's worries. Contemporary portraits always display the prince from the left, never revealing the likely disfigured right side. While the prince had a wild and adventurous youth, King Henry V was a pious and disciplined leader during his reign.[46]
This video shows a reenactment and reconstruction of the procedure and tools used.[47]
Birth of Modern Surgery
The Renaissance was the beginning of modern medicine because the higher standards of art required a more accurate understanding of anatomy. The great Florentine sculptor, painter, and printmaker Antonio Pollaiuolo shows naked men in striking poses in his influential wood carving, Battle of Naked Men. Accurate anatomical knowledge via dissection was required to correctly depict the bone and muscular structure to meet the patron's exacting standards.[48] Chronicler Giorgio Vasari’s Lives of the Artists states that Pollaiuolo was “the first master to skin many human bodies to investigate the muscles and understand the nude in a more modern way.”[49] Both Leonardo da Vinci and Michelangelo performed dissections and set higher standards for anatomical accuracy, which prompted more artists to undertake dissections and record their findings. Artists would perform exhaustively detailed studies of nudes and specific body parts, while others performed rigorous dissections and produced breathtaking works of anatomical accuracy for artistic reference.
Two Flayed Men and Their Skeletons, Domenico del Barbiere, circa 1540 –45. [50].
Courtesy of Metropolitan Museum of Art. Public Domain.
Building off the newfound anatomical knowledge and questioning of traditional medieval ideas about medicine, barber-surgeon Andreas Vesalius spent years performing dissections at various universities and published the largest, most accurate anatomical work specifically for medicine. His work De humani corporis fabrica libri septem (“The Seven Books on the Structure of the Human Body”), commonly known as the Fabrica, was printed in 1543 and redefined physiology, created anatomy as its own field of study, and helped to discredit the ideas that had governed medicine in Europe for over a thousand years.[51]
From the Fabrica, one of the most detailed and anatomically accurate depictions of the liver and kidneys of its time. [52].
Courtesy of Andreas Vesalius. Public Domain.
Often regarded as the father of modern surgery, Ambroise Paré was a French surgeon who enlisted in the French army as a surgeon in 1537. He quickly noticed the abhorrent condition of battlefield surgery during the age of firearms. He shunned the practice of treating gunshot wounds with boiling oil and instead used a mixture of egg yolk, rose oil, and turpentine. Not only was this less toxic to the wound, but it was less traumatizing to the patient; and he noticed that his patients recovered faster and more often than those treated with oil. He also advocated for tying large arteries during amputation rather than cauterizing them; refused to castrate patients who needed hernia surgery, introduced artificial teeth and limbs, and invented many new instruments—including the tourniquet.[53][54]
Paré on the battlefield using ligature to control bleeding after an amputation. [55].
Courtesy of Wellcome Images, Charles Maurand. Creative Commons (BY-SA).
Born in 1560, Fabricius Hildanus, the father of German surgery, was as prolific as he was knowledgeable. He published books on gangrene, lithotomy, gunshot wounds, military medicine, plague epidemics, burns, mineral baths, and the uses of anatomy. He developed new amputation techniques (like integrating the tourniquet), divided burns into three classes of severity (as is still practiced today), and made several major contributions to neurosurgery.[56] He developed new tools to treat depressed skull fractures and he also expanded surgical knowledge in how to access the brain through the skull and dura mater (the thick membrane of connective tissue around the brain and spinal cord).[57]
One of Hildanus' inventions to access the skull and correct depressed skull fractures. [58].
Courtesy of Wellcome Images. Creative Commons (BY-SA).
Works Cited
Footnotes
1. Leigh Ann Craig, PhD, “Medival Medicine, Dr. Craig.”
2. brothers, Very Rich Hours of the Duke of Berry English.
3. “Hippocrates | Biography, Definition, & Facts.”
4. “Hippocratic Oath.”
5. “Hippocratic Oath.”
6. “Hippocratic Oath -- Britannica Academic.”
7. “450px-Hippocrates_title_page_Froben.Jpg (450×600).”
8. “Galen of Pergamum -- Britannica Academic.”
9. Anathomia. 53v “Wound Man.”
10. “Medicine, Diagnosis and Treatment in the Middle Ages.”
11. Anathomia. “Muscle Man” in Red and Black.
12. “Medicine, Diagnosis and Treatment in the Middle Ages.”
13. Bloodletting Man Showing the Influence of Zodiac and Planets.
14. Leigh Ann Craig, PhD, “Medival Medicine, Dr. Craig.”
15. Prioreschi, “Determinants of the Revival of Dissection of the Human Body in the Middle Ages.”
16. Leigh Ann Craig, PhD, “Medival Medicine, Dr. Craig.”
17. Lemmens, English.
18. master, English.
19. Leigh Ann Craig, PhD, “Medival Medicine, Dr. Craig.”
20. “The History of Bloodletting | BC-Medical Journal.”
21. “The History of Bloodletting | BC-Medical Journal.”
22. Tomyarbro, English.
23. Leigh Ann Craig, PhD, “Medival Medicine, Dr. Craig.”
24. “Facts About Cataract | National Eye Institute.”
25. “Cataract Surgery - Mayo Clinic.”
26. “The History of Cataract Surgery.”
27. Leigh Ann Craig, PhD, “Medival Medicine, Dr. Craig.”
28. Unknown, Deutsch.
29. “The Definition of Hernia.”
30. “Inguinal Hernia - Symptoms and Causes.”
31. “Inguinal Hernia - Diagnosis and Treatment - Mayo Clinic.”
32. Leigh Ann Craig, PhD, “Medival Medicine, Dr. Craig.”
33. Leigh Ann Craig, PhD.
34. Leigh Ann Craig, PhD.
35. Hager, The Demon Under the Microscope.
36. “Anatomy and Surgery in Europe and the Middle East during the Middle Ages.”
37. “Anatomy and Surgery in Europe and the Middle East during the Middle Ages.”
38. “Anatomy and Surgery in Europe and the Middle East during the Middle Ages.”
39. “Anatomy and Surgery in Europe and the Middle East during the Middle Ages.”
40. “File:Einhard Vita-Karoli 13th-Cent.Jpg - Wikimedia Commons.”
41. “Trephination.”
42. “Trephination.”
43. “File:Peter Treveris - Engraving of Trepanation for Handywarke of Surgeri 1525.Png - Wikipedia.”
44. “Wayback Machine.”
45. Altman, “Historical Maxillofacial Surgery.”
46. “Prince Hal’s Head-Wound: Cause and Effect - Medievalists.Net.”
47. WillieWillieHarrySte, Henry V Arrowhead Removal.
48. Bambach, “Anatomy in the Renaissance | Essay | Heilbrunn Timeline of Art History | The Metropolitan Museum of Art.”
49. Bambach.
50. Barbiere, Two Flayed Men and Their Skeletons.
51. “Andreas Vesalius | Belgian Physician.”
52. “File:Vesalius Fabrica P372.Jpg - Wikimedia Commons.”
53. “Ambroise Paré | French Surgeon.”
54. “Petit-Type Tourniquet, London, England, 1823-1829.”
55. Ambroise Paré, on the Battlefield Using a Ligature for the A.
56. “Fabricius Hildanus – Father of German Surgery | Hektoen International.”
57. Tubbs et al., “Wilhelm Fabricius von Hilden (Guilhelmus Fabricius Hildanus) 1560–1634.”
58. G. Fabricus Hildanus, Observationum et Curationum...
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