Medieval Germ Theory?

It was Ignaz Semmelweis in the 1840s in Vienna who noticed a link between illness (and death) and unsanitary conditions, specifically a link between women dying during childbirth who were aided by people who also were performing autopsies. He spent years trying to implement a universal handwashing policy. He did not know what was causing the deaths, but he saw a link to something.

Figuring out the cause of disease was a goal for anyone practicing medicine from the beginning of the discipline. Long before germ theory was developed, the miasma theory was proposed by Hippocrates (c. 460 – c. 370 BC): that some form of "bad air" or even "bad water" arising from rotting matter caused diseases like the Black Death, cholera, and other infections. This was an important move away from the theory of supernatural causes of illness. (There was also the idea of an imbalance in the body's natural humors.) The miasma theory allowed infection to pass through a population because of the environment, not from personal contact.

To counter bad air, you would naturally want "good air."  medical faculty of the University of Paris, writing in 1348 to explain the causes of the Black Death, said "The present epidemic or pest comes directly from air corrupted in its substance" and recommends incense which "hampers putrefaction of the air, and removes the stench of the air and the corruption [caused by] the stench."

Earlier, however, there were counters to the miasma theory.

The Classical Era and Middle Ages did have theories of person-to-person contact. Thucydides (c.460BCE - c.400CE) believed that the plague of Athens was being spread by personal contact. Galen (129 - c.200CE) referred to "seeds of plague" in the air. Isidore of Seville also mentioned "plague-bearing seeds." Avicenna (c.980-1037) was widely studied, and he linked the miasma theory with personal contact, believing an ill person could infect others by transmitting the "bad air" through breathing. His example was tuberculosis, and he believed that disease could also be transmitted through dirt and water, anticipating Semmelweis by 800 years.

Recent posts have mentioned Bologna as an important center for medical study, so it is not surprising that it was a professor of Bologna, Tommaso del Garbo (c. 1305–1370), who in 1345 promoted Galen's "seeds of plague" idea in his works

It took Girolamo Fracastoro in 1546, however, to publish De Contagione et Contagiosis Morbis ("On Contagion and Contagious Diseases"), three volumes on different diseases and their avoidance and treatment. He believed that there were particles that could travel through the air or by direct contact.

The idea that these "seeds of disease" were living things (what we call "germs") and traveling from one person to another was not being entertained, simply because there was a long-standing theory that living matter could arise spontaneously from putrefaction, and no one believed in invisible living things floating in the air. The belief that life could spring from rotting organic matter hindered understanding of bacteria already existing in the air around us. As it turns out, there were plenty of examples of Spontaneous Generation; let's talk about those tomorrow.

Theodoric Borgognoni

Speaking of surgery recently, we need to take a look at Theodoric Borgognoni, who pioneered some practices that were ahead of their time. Born in Lucca in 1205 to a physician and teacher, Hugo Borgognoni, he was destined for a medical career. He studied medicine at the University of Bologna. He also became a Dominican, then the personal physician to Pope Innocent IV, was made Bishop of Bitonto, and eventually became Bishop of Cervia.

Although he had ecclesiastical duties, he still practiced medicine and taught. One of his students was later the "father of French surgery," Henri de Mondeville. Borgognoni wrote the Chirurgia ("Surgery") in the mid-13th century, four volumes that cover what was known about surgery at the time, with his own additions. (A copy of the work created c.1300 on vellum was auctioned at Christie's a few years ago; a sample page is illustrated above.)

In the Chirurgia, he advocates many interesting techniques. Broken bones were a serious problem, and Borgognoni explained how to re-align the bones and tie them together with gold or silver wire. He also advocated post-operative massage of the area to aid proper healing.

Much of Chirurgia is similar to a work written 15 years earlier by Bruno da Longoburgo, but since both of them were students of Hugo Borgognoni, that can be expected. Borgognoni the younger, however, has plenty of ideas not found in the other work.

He departed from standard medical beliefs about pus. For centuries, pus bonum et laudabile ("good and laudable pus") in a wound was considered a sign of proper healing. There was some sense to this, because severe infection led to necrotizing tissue, which and looked very different was much worse. Pus was a different symptom, and looked to early doctors much better than the other option. Wounds that showed pus, therefore, would be left open to suppurate to support the healing process.

Borgognoni did not believe that pus in the wound was proper: he advocated cleaning and drying the wound, then suturing it:

"For it is not necessary that bloody matter (pus) be generated in wounds -- for there can be no error greater than this, and nothing else which impedes nature so much, and prolongs the sickness."

He also (which was not a unique idea) used wine to treat a wound. Now we know, of course, that alcohol in wine would help to kill harmful bacteria. Of course, wine for treating wounds did not automatically lead to the idea that a substance in wine was "killing" something in the wound. Wine was a good thing, and its goodness had healing properties—that was the thinking. It would take centuries to develop germ theory. There were, however, small steps in that direction, and I'll explain those tomorrow.

Aëtius of Amida and Acne

Galen was one of the primary sources of medical expertise in Antiquity and the Early Middle Ages, often to the neglect of other authors. The works of the 6th century Aëtius of Amida have more recently undergone closer scrutiny and revealed his originality and importance in his field.

He was born in Amida in Mesopotamia (what is now the city of Diyarbakir in Turkey), but at some point moved to Constantinople. His writings refer to Petrus—the personal physician to Theodoric of the Ostrogoths—as a contemporary, which would indicate that Aëtius was writing at the end of the 5th century or early in the 6th.

As a Byzantine Greek in the 5th-to-6th centuries, he was likely a Christian.  His closeness to the emperor(s) of Constantinople can be discerned by the title sometimes attached to his name in records: κόμης ὀψικίου ("komés opsikiou"), the "chief officer" who is part of the emperor's retinue. He might have been given official duties outside of his medical profession, since he traveled to copper mines on Cyprus, and at Jericho and the Dead Sea.

His great work was Sixteen Books on Medicine, which later editors thought to organize into four tetralogies. He does quote the Greco-Roman Galen and Oribasius (personal physician to the Roman Emperor Julian), but adds much original information. Some of his work directly applied to pregnancy—or rather, avoiding such. He is known to have developed a concoction for causing a pregnancy to abort; the ingredients are not known. He also developed a contraception medicine consisting of aloe, pepper, saffron, and the seeds of the wallflower (a member of the cabbage family).

He described a condition of the skin, a particular kind of blemish that arises when one is in the "acme" of his or her life, during puberty. Due to a typographical error, however, when he described it as part of the acme (ἀκμή) of life, the word was written as ἀκνή, accidentally substituting the "n" sound in place of the "m" sound. The word "acne" never having been seen before, it was assumed that this was his name for the blemishing, and the scourge of adolescent complexions through the ages got its name.

About his contemporary, Petrus; or rather, about Petrus' chief patient: I've referred to Theodoric more than a few times, but haven't yet dug into the details of the man who was king of one thing or another from 471 to 526—a pretty substantial length of time. It's time we looked into his life in a little more detail, which we shall do tomorrow.

The Poison that Cures

It started with King Mithridates IV of Pontus (132 - 63 BCE), who was afraid of being poisoned. He wanted to know all about poisons, so he not only tested them on criminals so he would understand their symptoms (and antidotes), but also he ingested the poisons himself in order to build tolerance. His personal physician developed for him a universal antidote which he named mithridatum, composed of 40 ingredients, including opium, myrrh, saffron, ginger, and cinnamon.

Mithridates' method of self-inoculation worked so well that, when he was captured by Pompey, he tried to poison himself, but the poison had no effect. His writings about developing the cure-all was found by Pompey's people and translated into Latin. Nero's physician added more ingredients, most notably mashed and roasted viper's flesh.

The search for a panacea, a universal cure, has a long history. Mithridatum is one example. The Greek physician Galen (mentioned many times in this blog) wrote an entire book on the making of his cure-all; he called it Galene after himself, but it also became known as theriac (from the Greek word for a wild beast); it contained viper's flesh, opium, honey, wine, cinnamon, and more than 70 other ingredients. It needed to ferment for six years and then be applied orally or topically; it kept its potency for 40 years.

In the 7th century a theriac made by the inhabitants of Anatolia was given to the emperor of the Tang Dynasty. The Tang apothecary declared its usefulness against a hundred illnesses. The Middle East called it Tiryaq. Medieval English apothecaries called it "Venice Treacle" because it came from the Mediterranean, and was distributed by the Worshipful Company of Grocers. "Treacle"? Yes. Produced from cane sugar, the thick and sweet syrup was considered "good for what ails you"; the word is actually linked to theriac. In modern medicine, the word "treacle" is defined as

A medicinal compound once in wide use as an antidote to poisons. Treacle was a kind of salve. It was reputed to be a remedy against venomous bites in particular and against poisons in general. It also came to be considered a "cure" for cancer. [source]

In Henry Grosmont's 1354 treatise,  Le Livre de Seyntz Medicines or "The Book of Holy Medicines," he mentions theriac: "the treacle is made of poison so that it can destroy other poisons."

You may ask: if they believed it was so effective, wouldn't they try to make vast amounts to keep on hand? Would they try it as a cure for the Bubonic Plague? Well, one man thought that was a good idea, but ... well, we can talk about him next time.

What About Soap?

Continuing our discussion about medieval hygeine, let's ask about soap and whence it came. The answer depends on how you define "soap." Technically speaking, "soap" is "material you get when you combine fats or oils with an alkali, such as lye." [FDA link]

Soap-like materials were being made in Babylon around 2800 BCE, in clay cylinders inscribed with the phrase “fats boiled with ashes.” Egyptians in 1500 BCE were combining animal and vegetable oils with alkaline salts for cleansing. A Roman legend claims that rainwater running down the slopes of Mount Sapo mixed animal fat and ashes, not only producing soap but giving the substance its name.

Pliny described soap as an invention of the Gauls, made from tallow and ashes. Latin sapo ("soap") may be cognate with Latin sebum ("tallow"). The physician Galen recommends soap for cleaning clothes as well as the body.

By the 7th century CE, Mediterranean countries were making soap using oil from the abundant olive trees. Naples even had a guild for soap-makers in the late 6th century. Records for Charlemagne's court list soap as a product the stewards had to account for.

Soap-making in England didn't seem to happen until the 12th century, possibly motivated by the introduction of soaps brought back by Crusaders from the Middle East. Syria, for instance, produced Aleppo soap, a green bar infused with laurel oil. This popular soap was milder and more pleasant smelling than other soaps, and inspired soap-makers to add aromatics to the mix.

Soaps are used for cleaning different things. The soaps used in the household for hand washing, etc., are called in the industry "toilet soaps." That term, as you can imagine, makes me think about medieval toilets, a topic I have never tackled (and only mentioned once) in almost 1200 posts. I think it's time to correct that omission. Stay tuned.

Scrofula and Magic

Scrofula, characterized by swellings on the neck, is caused when someone inhales air contaminated with mycobacterium. The bacteria infect the lymph nodes in the neck. In the Middle Ages it was called "The King's Evil" because of the belief that the Royal Touch could cure it. The word scrofula itself is a diminutive of the Latin scrōfa, "breeding sow," presumably because pigs were subject to the disease.

Treatment did not have to rely on the Royal Touch. Figwort was recommended because of the "doctrine of signatures."

The doctrine of signatures dates from antiquity; Galen and Dioscorides, who were sources of medical knowledge used for centuries afterward, describe the disease. It claims that herbs resembling parts of the body can be used to treat ailments of that body part. Figwort, when dug up, showed tubercles that resembled the swellings of the lymph nodes. Therefore, figwort was used to treat swellings such as scrofula.

Paracelsus (mentioned here) in the 1400s explained this thinking as "Nature marks each growth ... according to its curative benefit." A 17th century botanist, William Coles, justified the doctrine of signatures theologically, believing that God made 'Herbes for the use of men, and hath given them particular Signatures, whereby a man may read ... the use of them."

But back to figwort. When the urge came to carefully catalogue the natural world with scientific names, figwort became scrofularia nodosa because of its previous reputation regarding scrofula.

The Royal Touch was more than just a touch and for more than just scrofula. We'll look at some other diseases tomorrow.

The Invention of Acne...

A copy of his work [source]

...was a typographical error.

The word "acne" does not come from a classical language root; that is, not in the way we usually derive our modern medical terms. It was described by a Greek physician and then mis-transcribed in a later volume of his work.

Aetius of Amida was a contemporary of Theodoric the Great (454 - 526; mentioned here in connection with Grammar). He was known for the breadth of his learning; his writings show a great knowledge of those who came before him as well as personal skill. He came out of Mesopotamia and learned medicine at Alexandria, known for its medical school.

His famous work was Sixteen Books on Medicine, in which he compiles knowledge from Galen and others of whom we would otherwise have little information: the surgeons Rufus of Ephesus and Leonidas, and the obstetricians and gynecologists Soranus of Ephesus and Philumenus. He is not completely derivative, however. He includes original treatments for eyes, ears, nose and throat, as well as goiter and rabies and others. He also addresses surgical procedures such as for a fistula or tonsilitis.

Although a Christian, he was not immune to the cures that came from non-Christian sources. He relates spells and charms popular in Egypt at the time. Also, in explaining how to help a person suffering from a bone stuck in the throat, he makes the earliest reference to St. Blaise.

As for the condition in which the skin is covered with small eruptions or peaks, he used the Greek word ἀκμή ["acme"; point]. Unfortunately, a scribal error in a later copy turned this into ἀκνή ["acne"]. The popularity of his text made this the common name for the affliction, and so it remains.

A Pain in the Ass

(I apologize if the title—or the topic—is too crude for some.)

The poor fellow to the right (the one half showing) is suffering from an anal fistula, described thusly:

... a small channel that can develop between the end of the bowel and the skin near the anus.
... can cause bleeding and discharge when passing stools - and can be painful. ...
In some cases, an anal fistula causes persistent drainage. In other cases, where the outside of the channel opening closes, the result may be recurrent anal abscesses. The only cure for an anal fistula is surgery. [WebMD]

Nowadays it is called a "pilonidal cyst." At the very least, inconvenient; in many cases, extremely painful, especially when sitting down.

At a time when many men spent long stretches of time bouncing on horseback, these fistula-in-ano (to give it the Latin phrase) were debilitating. Fortunately, soldiers of Edward III's time had a solution in the skill of John of Gaunt's favorite physician and surgeon.

John Arderne (1307-1392) left us very little information about his early life. It seems he was a surgeon in Nottinghamshire. During the Hundred Years War, he probably traveled with the army; his writing suggests a well-traveled man with wide experience of the world as well as medical practices.

He produced the definitive work on treating this particular medical problem. His writing describes the cause and the treatment, and describes the surgical instruments needed for his procedures. He also shows knowledge of Galen & Guy de Chauliac, Avicenna, and Dioscorides.

Arderne was ahead of his time in some ways. He advised opium to dull pain during surgery, and the code of conduct proper for a physician. In the matter of fees, he was fine with charging a rich patient whatever the traffic would bear, but felt that the poor should be treated for free. He was also a great believer in cleanliness, and in not fussing with a wound once treated, but allowing the healing process to proceed untampered with.

That is not to say that he was "modern." He also subscribed to the belief that parts of the body were aligned with astrological signs, and that the time of the year could influence the efficacy of surgery on parts of the body.

Avicenna

In 1527, when the healer and alchemist Paracelsus wanted to display his contempt for tradition, he burned a book in the town square in Basle, where he had been appointed to the university by the town council. That book, allegedly, was The Canon of Medicine by Avicenna. Paracelsus had gone too far in rejecting what was still considered a fundamental work in western medicine. He was ejected from his post at the University, and from the town itself. Avicenna was too respected, even 500 years after he wrote his books.

Abū ʿAlī al-Ḥusayn ibn ʿAbd Allāh ibn Sīnā, called by the West Avicenna (c.980-1037), was mentioned here in the context of medicine. About 40 of the 240 surviving texts that he wrote (of a total of about 450!) deal with medicine. The encyclopedic Book of Healing and the Canon became standard textbooks for centuries.

The Canon assembled the best known medical knowledge to date, including Galen (129-c.200 CE) and Hippocrates (c.460-c.370 BCE) and adding a great deal of information that seems new to Avicenna. For instance:

The 'Qanun' is an immense encyclopedia of medicine. It contains some of the most illuminating thoughts pertaining to distinction of mediastinitis from pleurisy; contagious nature of phthisis*; distribution of diseases by water and soil; careful description of skin troubles; of sexual diseases and perversions; of nervous ailments. [George Sarton, Introduction to the History of Science]

Another reason why Paracelsus would want to burn Avicenna: Paracelsus was advertising his reputation as an alchemist, and believed that with salt, sulphur and mercury you should be able to produce anything. Avicenna, however, was completely opposed to the idea of alchemy, rejecting the notion that man could improve on Nature.

One could still work with Nature, however. Besides dealing with disease and injury (such as explaining how to judge how much healthy tissue could be removed during an amputation or the removal of cancerous tumors), Avicenna promoted restoring health, not just treating disease. He believed in the importance of physical exercise, of a good diet, and of a healthful environment.

Among other innovations, he lays the groundwork for modern ophthalmology, even suggesting that the optic nerves cross over each other. He laid out careful ground rules for the preparation, administration, and testing of drugs.

It has been called "one of the most significant intellectual phenomena of all times."** The Canon of Medicine is an essential part of any curriculum that studies the history of medicine.

*tuberculosis
**Swiss tuberculosis expert, Arnold Klebs

The Edict of Salerno

Salerno, located on the lower "shin" of Italy's southwest coast, has been occupied continuously since pre-historic times, frequently changing hands due to the many wars in the peninsula. Despite the changing political landscape, however, at least one feature of Salerno rose to a prominence that it held for several centuries, through several political shifts.

We don't know precisely when the Schola Medica Salernitana (Medical School of Salerno) was founded, but at some point, the dispensary of a 9th century monastery became a focal point for medical study and earned the title of the first medical school in history. Because of the fame of the school, Salerno became known as the "Town of Hippocrates."

The School today.

One of its unique qualities for the time was that it not only was well-versed in the Greco-Roman traditions of Hippocrates, Galen, Dioscorides and others. Its proximity to North Africa and Sicily gave it access to Arabic learning (Sicily was under Arab control from 956 until 1072). In fact, it was the arrival in 1077 of the Tunisian Muslim merchant-turned-monk Constantinus Africanus that started a Golden Age at the school. He compiled the Liber Pantegni (Book of All Arts).  It was (as is typical for the time) largely a collection of the work of others, but it drew together Greek and Arabic medical knowledge in what is called the earliest surviving Western medical treatise [source].

Salerno produced other medical texts as well. A 12th century pair named Johannes and Matthaeus Plantearius wrote the Liber de Simplici Medicina (Book of Simple Medicine). Several books on gynecology and cosmetics were created by the most famous woman doctor of the time.

Salerno thrived, even after Holy Roman Emperor Frederick II declared the Edict of Salerno. The Modern Age would approve of the Edict: it created a legal separation between physicians and apothecaries. Physicians could no longer prescribe medicines that they themselves prepared and sold. The Edict also fixed prices to prevent overcharging the sick. Over time, this Edict was copied throughout Europe, and we have reason to be glad that similar regulations exist today.

Great Surgeon

The history of medicine includes many brave and progressive thinkers who were not willing to follow the herd or be content with what was already known. One such in the Middle Ages was Guy de Chauliac. Born about 1300, he studied at a university in Montpellier known for its expertise in medicine. After becoming a Master of Medicine and Surgery around 1325, he went to Bologna for further study. His reputation became such that he was invited to Avignon to be personal physician to Pope Clement VI, then Pope Innocent VI and Pope Urban V. The papal connection gave him access to a library that included the texts of the Greek physician Galen in their original; most of Europe knew Galen through less accurate Latin translations.

He possibly saved Clement's life during the spread of the Black Death, when he advised the pope to stay near blazing fires. Although many physicians fled Avignon at the arrival of the Plague, Chauliac stayed to study the disease and treat people. He determined that it was contagious, but couldn't figure out the method of contagion. Still, he advised bloodletting, a healthy diet, and exposure to pure air (hence the fires, which would have serendipitously served to keep fleas away). He also realized that there were two diseases involved because of different sets of symptoms: the initial Bubonic Plague, and the follow-up Pneumonic Plague which found its foothold in the weakened population and killed much more swiftly. Chauliac spoke out strongly against those who blamed the Jews for the Plague, explaining that scientifically it made no sense to consider them at fault.

Tools for withdrawing an arrow.

His value to the rest of the world and history was the writing of Chirurgia magna (Great [book of] Surgery) in 1363. Its seven volumes covered every imaginable medical topic of the day: intubation, surgery, disease, anesthesia, hernia, cataracts, ulcers, bloodletting, cauterization of wounds, and the use of special instruments (some of which he designed himself, such as an elaborate contraption for withdrawing an arrow from flesh). Chauliac drew on the past, quoting Galen (129-c.200) and Avicenna (Abu Ali al-Husayn ibn Abd Allah ibn Sina, c.980-1037). He placed great emphasis on learning anatomy, saying that "A surgeon who does not know his anatomy is like a blind man carving a log."

Chauliac was not always accurate. He believed, for instance, that pus was an important part of the healing process and should be left alone. Nevertheless, his Chirurgia became a standard text for the next three centuries, translated into several European languages. Unfortunately for future generations, anti-Islam sentiment caused many translators to leave out knowledge from Islamic scholars, resulting in a less complete and less accurate work. Still, he has been labeled the "Father of Modern Surgery," and his great work was the standard text until the 17th century.