Urinalysis, Part 3

William of Malmesbury tells us that William the Conqueror fell from his horse in summer of 1087 while fighting on the continent and suffered painful internal damage. Physicians examined his urine and predicted imminent death. William died in September of that year. The diagnosis prompted him to receive last rights and arrange for his demise.

Abbot John of St. Albans was practiced at medical diagnosis through examination of urine. In 1214, John was ill and, suspecting the illness to be fatal, examined his urine and predicted he had three days to live. He was right.

The Trotula suggested a urine test to determine fertility. A husband and wife seeking to have a child should each urinate into a pot of bran. If in ten days the bran was stinking and full of worms, the person who urinated into it was the infertile one.

Raoul, the Count of Vermandois (reigned 1102 - 1152), fell ill, and his physician recommended he abstain from sexual relations with Raoul's just-married third wife. When the physician later examined Raoul's urine, he realized the advice was going unheeded. He told Raoul that he would be dead in three days. Raoul (we are told) died in three days. The urine told the tale of his activities in bed.

What happens if you pretend to be a physician and get caught? Let's look at the case of Roger Clerk of Wandsworth. Roger charged Roger atte Hacche 12 pence for a diagnosis and cure for Roger's wife that turned out to be a blank parchment wrapped in cloth of gold. Roger Clerk was brought to trial before the Mayor and Aldermen at the Guildhall of London in May 1382. It turns out Roger had no license or training to practice medicine, and the "cure" was fake. His punishment was to be paraded in the streets, sitting backwards on a saddle-less horse, two urine flasks hanging around his neck.

But enough about urine for now. What other punishments might be meted out for offenders? Let's look at some of the judgments set out for those who committed crimes in Medieval England, starting tomorrow.

Urinalysis, Part 2

We started a conversation yesterday on the use of urine by medieval Western European physicians to determine health. I thought today we'd go into exactly how the urine was an indicator of health.

Examining sediment in the urine was one case, which was described yesterday in a paragraph from Giles Corbeil's (fl.1200) poem De urinis. Later elaborations on this suggest the urine would settle into layers of different colors. A large layer on top could indicate a problem with the head. Some sediments indicated kidney stones.

Smell and taste were also ways to examine urine. Smell was obvious, but taste was also used at times; sweetness was an indication of diabetes.

Visual examination was the first and most common method, and was the reason why a glass flask became the symbol in illustrations of a physician. Hippocrates (c.460–375 BCE) started the business of the look of urine having significance. He felt it was the output of all four humors of the body, could indicate which was deficient or superabundant, and could be used to predict the progress of a disease.

White or pale yellow urine was healthy, but black or foul-smelling urine predicted an increase in disease. White sediment meant the illness would be long but not fatal. Completely colorless urine was the sign of a disease of the brain (these days it means excess hydration with water).

If there were bubbles in the urine, long-term kidney disease was the cause. The modern term proteinuria is now used for this condition, denoting protein in the urine and indicating damaged kidneys.

In the circular diagram above (found in the 14th-century manuscript Bodleian Library MS Savile 39), we see the "color codes" for urine. They range from the pale urine of decent health to the reddish-gold denoting healthy digestion to the dark flasks of impending death.

Urine travels in containers, and could be collected and sent to a physician or an expert urologist if you had none nearby. Isaac Judaeus, an expert on urology, criticized this idea; he believed diagnosis without seeing the patient in person was pointless.

Tomorrow we'll discuss the punishment for urinal malpractice, and look at a couple urinalysis patients.

Urinalysis, Part 1

Last post mentioned that a medieval illustrator indicated a physician by showing him holding a flask. There was a very specific substance in that flask, and it wasn't blood; it was urine. Blood's color rarely looked different from person to person or ailment to ailment, but urine could be different in many ways.

I talked about a book all about urine a few years ago, but let's get into some more detail now.

Medieval physicians saw at least 20 different visual cues in urine when assessing a patient's health. This was such a common practice in Western Europe that William of Rubruck, writing about his travels in the Mongol Empire for Louis IX of France, mentions his surprise that their physicians didn't examine urine.

Let's look at some of the statements made by Giles Corbeil (fl.1200) in his 352-verse De urinis, written for students about uroscopy. He starts with the basics:

The physician who wishes to be considered an expert judge of urine must consider with care the following things: what sort, what it is, what is in it, how much, how often, where, when, age, nature, sex, exercise, anger, diet, anxiety, hunger, movement, baths, ointment, drink.

He explains what healthy urine looks like; it seems the flask of urine is swirled and then sediment is allowed to settle:

Color, consistency, duration, form, and place are the determining characteristics of urinary sediment. The color should be white, the consistency continuous, the form conical, the place the bottom of the vessel, and the duration marked. If the sediment is all these – white, continuous, lasting, conical – digestion will be good, virtue strong, and natural action will flourish with a triple activity: it whitens, it cleanses, and it condenses, concentrates, and unites.

The smart physician could also predict death from urine:

A very limited quantity of urine, passed with difficulty, livid and oily, foreshadows death. Urine tinged green indicates jaundice, spasm, severe fever, and finally death.

We'll look at more methods of diagnosis tomorrow, as well as some specific cases.

Blood & Health

We've been talking about blood as food, and some recipes using blood in cooking, but now let's talk about health-related blood.

Blood was considered one of four "humors" that were the key to health and personality. I wrote about these humors before. When the four humors were in balance, health was maintained.

Hippocrates would have it that "The people who have red blood are friendly. They joke and laugh about their bodies, and they are rose tinted, slightly red, and have pretty skin." The adjective sanguine to denote a person who was optimistic or notably positive in their outlook starts in the Middle Ages. The word comes from Old French sanguin(e) "blood red," from Latin sanguineus "of blood," from sanguis, "blood."

The other humors were yellow bile, phlegm, and black bile, but blood was the easiest one to see. Galen believed that blood carried the pneuma, the spirit, which accounted for its red color. Blood was associated with the element of air, and an excess of blood was thought to be responsible for inflammation, fever, and aggression.

To rid a suffering person of excess blood, phlebotomy, the practice of opening a vein and letting blood out, was developed. Ancient Egypt and the 5th-century BCE time of Hippocrates used bloodletting to help patients heal from illness. Just as menstruation was believed to purge women of "bad humors," bloodletting became a common technique.

In 1163, Pope Alexander III decided it was inappropriate for monks and priests to shed blood (repeated at the Fourth Lateran Council), so their time as practitioners of the medical techniques came to an end. Clergy could still be physicians, but not surgeons.

Medieval art symbolized a physician with a man holding up a flask. That flask, however, was not filled with blood.What it was filled with, and how it was used to diagnose illness, we'll discuss next time.

Isaac Judaeus

An Andalusian Arab named Ibn Juljul wrote Ṭabaqāt al-aṭibbā’ w’al-hukamā’ ("Generations of Physicians and Wise Men") in the late 900s. It is one of the only sources for biographies of several early scholars, philosophers, and doctors. In it we learn details about the life and career of Isaac Israeli ben Solomon, who is sometimes called simply Isaac Judaeus.

He was born in Cairo and became known as an oculist (we've talked about medieval eye treatment before).  About 904 he became the court physician to Prince Abu Mudhar Ziyadat Allah III in Kairouan, capital of Tunisia. He studied general medicine while there.

After the death of Ziyadat in 909, Isaac became doctor to Caliph 'Ubaid Allah al-Mahdi, the founder of the Fatimid dynasty. The caliph enjoyed the witty repartee of his Jewish physician. Isaac began lecturing on medicine, and many people came to hear him speak as his fame spread. He continued to learn, studying astronomy, mathematics, medicine, and natural history.

He wrote medical manuals in Arabic which, in the Arabic-speaking world, were considered gems, but were unknown in Western Europe. The 12th century saw translators in Toledo striving to make many works available to a wider audience. Gerard of Cremona translated Isaac's Liber de Definitionibus (Book of Definitions) and Liber Elementorum (Book on the Elements) into Latin. Christian scholars started noticing his work, such as Albertus Magnus, Aquinas, Roger Bacon, Nicholas of Cusa, and Vincent de Beauvais.

One of his works dealt with the urinary tract, which I covered a few years ago.

The years of his life are given as different dates according to the source. Encyclopedia Britannica says born 832/855, Egypt—died 932/955) and that he lived more than 100 years. His death has been declared as 932, 940, 942, 950, and 955.

One of his pupils, Dunash ibn Tamim, wrote a commentary on a work of Jewish mysticism that quotes Isaac so extensively that later scholars thought it was written by Isaac himself. Dunash and this work, the Sefer Yetzirah, will be our next line of topics.

Gilbertus Anglicus

I've talked before about John of Gaddesden, a late-13th-century doctor who wrote a compendium of medical knowledge. A little before him was another who created an encyclopedic work about what was known at the time of medicine and surgery.

His name was Gilbertus Anglicus (c.1180 - c.1250), called so because he was born in England, although after some initial education in his home country he went to Europe to study, particularly at the Salerno medical school. He actually returned to England for a time to assist a bishop, but that bishop died in 1205 and Gilbertus went back to Europe.

After 1230, he produced a seven-volume work in Latin called Compendium Medicinae. This work was copied and distributed as one of the foundational works of medical education for centuries (along with Gaddesden's). It was translated into Middle English in the early 1400s. It first saw formal print in 1510 with further editions, one as late as 1608. Chaucer includes him in the Canterbury Tales as one of the great physicians.

Among its seven volumes was a section on gynecology that was sometimes circulated separately as The Sickness of Women. Later it was called The Sickness of Women 2 after having a different author's work added. These became even more widely distributed than the Trotula.

One of the aspects that made Gilbertus' Compendium so valued was its inclusion of the knowledge of so many others. Pythagoras, Hippocrates, Plato, Aristotle, Galen are there, of course, but also Avicenna and Averroes, Macrobius, Boethius, several Arabians, Isaac Judaeus, and the Salernian writers.

Isaac Judaeus was mentioned briefly here regarding Charlemagne and an elephant, and I'd like to tell you more about him, starting tomorrow. Isaac, that is, not the elephant.

How Babies Develop

We've been looking at the Medieval theories of women's reproductive systems and conception, and now it's time to see how they thought the fetus developed into a human being.

One point made in the De Secreta Mulierum, "Of the Secrets of Women," is that the fetus uses as a template (my word) not the limbs and physical features of the parents, because if a parent is deformed or blind the baby does not come out deformed or blind. Therefore, the template or "starting point" (again, my term) for a fetus must be:

 ...drawn from the four principal members, namely the cerebrum, heart, liver, and female womb or male testicles, and as a consequence it is in these members and not in other parts of the body that the fetus is said to resemble the parents.

So through what stages of development will the fetus go? You will be interested to know that:

The first matter received in the womb has the nature of milk for the first six days, for the natural heat in the male sperm and in the womb causes it to become white as milk. Then that matter is changed to the nature or color of blood that is thickened, as if it were well cooked, and this lasts nine days. During the next twelve days the members of the fetus begin to be formed.

Which organs develop first? Some say the liver, but the author of the Secreta agrees with Aristotle that it must be the heart, since the heart is "the first to live and the last to die." The heart is followed by the liver, then cerebrum, then sexual organs, etc. We also learn:

Note that with respect to the formation of the fetus the face comes first, that is of the extrinsic members, because the face of a human being is the noblest of these members.

After 33 days the form of a male or female appears, and after forty days the human nature is complete and the infant grows and opens his mouth, and his bones begin to enlarge from his natural heat.

Besides what is happening inside the womb, there are external forces that affect the fetus. Tomorrow we will look at how astrology is involved with fetal development.

Whence Do Babies Come?

Before modern medicine and studies of biology, theories of how babies developed in utero were "best guesses" based on what was observable externally. Yesterday's post related the notion that conception takes place when the seed from the father is exposed to the menses of the mother, which essentially is "food" that the seed uses to produce a baby. (This was opposed to Aristotle, who believed that the menses was the sole generating factor of the baby.)

A debate over the exact method of conception/gestation was explained in De Secreta mulierum, "Of the Secrets of Women":

Note that there is a controversy between medical authorities and philosophers, for philosophers say that the male seed has the same relationship to the female menses as an artificer does to his work. For just as a carpenter alone is the efficient cause, and the house is the effect, in that he alters and disposes the matter of the house, so the male seed alters the female menses into the form of a human being. ...

The medical authorities say the opposite, however, because man is made from the most noble material, and thus the male seed must enter the fetus materially, because the female menses is a superfluity of the second digestion and the male seed is better cooked and digested. Therefore it is necessary that it enter into the matter and substance of the fetus, for it is seen that sometimes the fetus resembles the father in genitals and in other ways, and this would be impossible if sperm were not incorporated materially. [translation by Helen Rodnite Lemay]

So philosophers (mostly male) believed that the male's seed is in the role of an artist and shapes the baby using material found inside the mother. Those who make a more clinical study of the human body were coming from what they observe of other creatures' life cycles, and believed that both bodies produced an amalgam that could become male or female. In other words:

The doctors say further that in the male seed there is a certain generating spirit which penetrates the entire seminal mass, and this spirit has the power to form all members. Just as a smith fashions iron with a hammer, this spirit disposes and softens all the members, and it is this spirit that is the efficient principle.

The philosophers, on the other hand, state that the male seed exudes as a vapor, for the womb is exceedingly porous and after the formation of the fetus the heat of the sun causes the male seed to evaporate and to leave the womb through the pores. It is evident that the womb is porous because the child receives nourishment through the pores.

I don't know what they thought the umbilical cord was for. I find references to clamping and cutting it, but not any theories as to why it existed. But here we have competing theories as to how the baby is conceived. The next question is how exactly does that small event produce a fully-formed human? Tomorrow we'll look at the chapter of the Secreta that deals with the formation of the fetus over time. See you soon.

(The illustration is actually the birth of Moses from the 14th-century Queen Mary psalter.)

Medieval Cataracts and Couching

A cataract is a medical condition where the lens of the eye becomes increasingly cloudy, leading to blindness. You would think that the Middle Ages had no way to treat this condition, but you'd be wrong. There was a method used that was actually developed thousands of years ago and described in medical texts. It was called "couching."

Couching is described in Greek and Sanskrit documents. It involves pushing the cloudy lens away from the pupil and into the interior of the eyeball, allowing more light to enter. This was done by inserting a thin sharp needle into the eye through the pupil and, well, simply pushing the lens until it is no longer blocking the light. This was done, of course, without access to anesthetics.

The result was more light, but the light was no longer being focused. The client's world was blurry—assuming the client was not rendered completely blind by damage to the eyes or killed by infection.

Roman artifacts found in the British Isles suggest that the technique was introduced there during the Roman occupation, and perhaps survived throughout the early Middle Ages, although we know of no cases prior to the 1560s.

Physicians and surgeons elsewhere knew of it. John II of Aragon went blind from cataracts by the time he was 70. A physician in his employ, a Jew named Abiathar Crescas, performed couching in September 1468 and restored his sight—or what there was available considering the lack of a functioning lens. John lived until the age of 80.

John's son, Ferdinand, would later, along with his wife, Isabella of Castile, expel all Jews from Spain. This was a major change in policy, since Jews had been prominent in the Court of Aragon. Tomorrow we'll look at the relationship between Aragon and Jews.

Amber, Medical and Mystical

Besides being attractive and easily carved into jewelry, amber was considered special in many ways. Its special attributes were first described by Pliny. Pliny did not follow Ovid's idea that amber was the hardened tears of a Greek goddess; he figured out it was likely tree sap:

Amber is produced from a marrow discharged by trees belonging to the pine genus,... It is a liquid at first, which issues forth in considerable quantities, and is gradually hardened [...] Our forefathers, too, were of opinion that it is the juice of a tree, and for this reason gave it the name of succinum, and one great proof that it is the produce of a tree of the pine genus, is the fact that it emits a pine-like smell when rubbed, and that it burns, when ignited, with the odor and appearance of torch-pine wood. [Natural History. Book 37.XI]

That did not mean, however, that he did not make note of its supposed special properties:

... Amber, indeed, is supposed to be a prophylactic against tonsillitis and other affections of the pharynx, for the water near the Alps has properties that harm the human throat in various ways.

Pliny also noted that "It is of benefit to babies when it is attached to them as an amulet." Amber was commonly used as magical amulets or talismans, either carved into a significant shape, or inscribed with a phrase that provided protection. The one shown here of a mother and child might have been designed to promote the health and welfare of both.

Another quality was noted in an article on the Getty website. "Amber could also symbolize constancy. Amber necklaces were gifts for brides, mortal and immortal, as the ancient sources tell us." [link] This is interesting because amber, unlike other precious and semiprecious materials, starts out with a luster from polishing that is very attractive but is anything but constant. Amber loses its luster and translucency over time, and amber items carved centuries ago are nowhere near as attractive to look at as they were at the time of creation.

Despite Pliny, the Middle Ages still looked to a link between amber and the sun, due to its golden color (when new). The most prominent belief was that amber was protection against negative influences, warding off evil spirits and bringing good luck.

The type of magic mentioned in the previous paragraph—intended to ward off evil spirits or other harmful influences—is called apotropaic magic, and has been very popular throughout history. Let's take a look at some examples tomorrow.

Arderne's Medical Manual

John Arderne (1307 - 1392), of whom I first wrote many years ago, has been called the father of English surgery. He earned this by producing a manual in Latin that was copied into English and widely used.

Although we know little of his personal life except that he practices in Nottinghamshire and London, his broad knowledge suggests someone who traveled and had a variety of experiences. Since he lived through the Black Death and the Hundred Years' War (during which he saw action in France), he had plenty of opportunities to learn about and deal with a wide variety of illnesses and injuries.

In 1370 he wrote the Practica Chirurgiae ("Practice of Surgery"), in which he detailed many of his techniques and boasted a for-his-time astonishing survival rate of 50%. There are not only detailed instructions, but detailed illustrations of the parts of the body being operated on, as well as illustrations of the instruments (many of which he designed) used.

More than the practical side of things, however, he gave advice to the surgeon open dress and behavior. He urged the university-trained doctor to dress the part, rather than wear the limited short (above the knee) robe of the typical "barber surgeon" (educated in a guild), to appear more important. Barber surgeons were looked down upon, and he advises his readers not to share techniques with them, lest they usurp the position of the university-educated surgeon. In a later century, in Paris, a distinction was made with the titles "Surgeons of the Short Robe" (who could offer their services never having taken an exam or proved their knowledge) and "Surgeons of the Long Robe."

Arderne's advice went beyond haughty classism, however. He also advised a pleasant bedside manner: the doctor should be able to tell tales "that may make þe pacients to laugh" and tales from the Bible to "make or induce a liȝt hert[light heart] to þe pacient or þe sike [sick] man." He should also, when speaking to a patient, not confuse him with complicated terms or harsh language:

“be the wordeȝ short, and, als mich as he may, faire and resonable and withoute sweryng”

make the words short, and, as much as he may, faire and reasonable and without swearing.

He felt that wealthy patients should be charged as much as possible, but poor patients treated for free.

More than 50 copies of his Practica exist today; 36 of them are copies with the original 250 illustrations. The expense of reproducing so many illustrations was significant, but it is a testimony to how valuable the work was considered to be. The illustrations were not only important to show how the body was being treated, but to understand the use of the instruments. These tools of the trade were not readily available, and had to be custom-made. I feel not enough has been said about the relationship of people with specific requests to the metal-workers of the age, so tomorrow let's talk a little about the blacksmith trade.

The Father of English Surgery

John of Arderne (1307 - 1392) was an innovative English surgeon who devised a number of cures and procedures and is considered the first English surgeon.

He grew up in Newark-on-Trent, which in his lifetime was a fairly large town. It is believed he attended the University of Montpellier; if so, then he may have been exposed to the Practica Chirurgia of Roger Frugard. He was in London in 1370, and was active in the Hundred Years' War in the regiment of Henry Grosmont, Duke of Lancaster, and John of Gaunt (King Edward III's son and Henry's son-in-law). (Incidentally, this would put him in the orbit of a young Geoffrey Chaucer.) He remained an employee of Gaunt.

War creates injuries, and this is where surgeons are most needed and are given opportunities to come up with new ideas for treating people. Long stretches bouncing on horseback can be damaging and lead to an issue now called a pilonidal cyst, but described by Arderne as a fistula in ano ("fistula in anus"). A fistula is a connection between two parts of the body that don't normally connect. You can learn more about this and Arderne's painful-but-successful treatment in this post.

But perhaps not so painful. Arderne knew of the soporific and nerve-deadening effects of opium, and prescribed it so that the patient "shal sleep so that he shal feel no cutting." To the opium he would add hemlock and henbane. He would apply this topically via an enema, and also use it on arrow wounds to deaden the pain while they were extracted.

His innovations were not just in what he was able to do for patients, but also in the profession itself. He believed, for instance, that wealthy patients should be charged what the market would bear, but poor patients should be treated for free. He also suggested ways to con duct oneself as a surgeon, and what to wear. The frontispiece for one of his manuscripts (shown above) shows him dressed in the robes of a university doctor, elevating the status above that of the more mundane "barber surgeon" who (because they possessed razors) were used to quickly treat war-related amputations, blood-letting, and (of course) hair-cutting. Because of the messiness involved, barber surgeons wore short robes. Arderne advised against this, urging his followers to distinguish themselves from the less-educated barbers.

More than 50 medieval manuscripts exist today with his texts, most with multiple illustrations as well. I'll share more of his guide for successful surgeons tomorrow.

Roger Frugard's Chirurgia

Roger Frugard (pre-1140 - c.1195) was also known as Rogerius, and sometimes called Roger of Salerno because he taught and worked at the hospital there (but not to be confused with the Roger of Salerno who was a regent of Antioch during the Crusading period). We don't know much about his life, but c.1180 he produced Practica Chirurgia ("The Practice of Surgery") with a no-nonsense approach to the subject.

Rather than write long pre-ambles, quoting Hippocrates or Galen or other surgeons and doctors on which much of 12th-century surgical knowledge was based, he gives clear and brief explanations for how to treat different illnesses and injuries. His writing provided the first Western European practical manual for teaching surgery. It was duplicated and used in universities at Bologna and Montpelier. Besides describing surgical techniques, he also described how medicines were prepared and applied, and how to diagnose illnesses. He was the first to use the word "lupus" to describe a rash that appeared on the cheeks.

In the 13th century, an Anglo-Norman translation was made and illustrated (above you see the dispensary and a doctor instructing his students). Though written in French, it was likely written in England because English terms are used throughout the text. This manuscript is now in the Trinity College Library collection. One of the delights of the illustrations is the facial expressions given to the patients, indicating the level of (dis)comfort they are going through. Also, surgical instruments are drawn with admirable accuracy.

(There are errors, however, due to sloppy reading of the text. One illustration is supposed to depict a condition that causes a blackened tongue, but the illustrator painted the tongue red. In another section on nasal polyps, the copyist did an "eye skip" where, while looking from original to copy, his eye skipped to a later occurrence of a word he just wrote, omitting the section in between. These errors can be determined by comparison to other manuscripts, and show that the copyist was not paying close attention to textual comprehension.)

Medieval surgeons were always looking for new ways to treat injury:

For example, it is believed that Roger of Salerno may have originated a technique for detecting a tear in the dura or cerebral membrane in skull fractures. Now known as the Valsalva maneuver, the doctor would have his patient hold their breath, introducing pressure into the skull, and the doctor would watch for air bubbles or cerebrospinal fluid leaking from the skull. Additionally, Roger was a pioneer in the treatment of nerve damage, advocating reanastomosis – the realignment of damaged tissue by surgical means – to repair severed nerves. [source]

The illustration of the dispensary above is in the section about treating fistula. This brings us to one of the most painful and "icky" treatments, but also to one of my favorite figures in medieval medicine, John Arderne, whom I'll tell you about tomorrow. 

Medieval Surgical Procedures

Yesterday's post took a turn toward a particular surgical procedure, so I thought we'd talk a little more about that topic. What procedures were known and practiced with evidence of patient survival, back when doctors believed in the Four Humors of Hippocrates? I have talked about medicine numerous times, so here I want to focus on actual invasive practices with instruments.

Purging was one of the most common forms of surgery, piercing a vein to let out blood because a person's fever or angry nature indicated an excess of blood.

Amputation was another fairly common practice when a limb was so damaged by accident or warfare that there was no chance of it healing. Unfortunately, surviving an amputation was not always assured. An interesting article by the National Library of Medicine points out early art of people with crutches that supports their educated medical opinion that a leg amputation was only likely to survive if it were below the knee. Above the knee amputation led to too much bleeding. [link] Presumably amputations of smaller parts—toes, fingers, arms up to elbows—were less of a problem.

Related to amputation was cautery/cauterization, sealing off blood vessels by heating iron and pressing it to the wound. In an ideal situation, the wound was sealed, bleeding was stopped, infection did not occur, and the patient would survive. Even in this situation, however, the process caused intense pain, especially if you accepted the treatment for hemorrhoids that involved inserting a hot poker. This did not work, nor did the non-surgical suggestion of going to sit on the rock where St. Fiacre was cured of hemorrhoids. [link] (Maimonides finally wrote a seven-chapter treatise on the subject ultimately suggesting a good soak in a bath.)

Dental surgery was not unknown. Toothache was a major problem in the Middle Ages, and extractions were common. Situations arose, however, whose descriptions suggested the client had oral cancer. Roger Frugard (pre-1140 - c.1195), a surgeon in Salerno, wrote a Practica Chirurgia ("Practice of Surgery") in which he describes cancer in the jaw:

"if the flesh is hard, perforated and blackened' ('Si la char est dure, perse e anercie') cancer ('cancre') of the mouth was difficult to cure."

He describes cutting into the healthy flesh around the hard cancer, cauterizing the wound, and sealing it with muel de oef ("egg yolk"!).

Trepanning—boring a hole in the head to relieve pressure—is the oldest surgical procedure for which we find evidence: Skulls—many hundreds of them—that were trepanned have been found dating back 7000 years ago and more, with evidence of healed bone around the edges showing that the patient lived. The circumstances under which it was decided to drill a hole in the cranium are unknown.

Cataracts were originally dealt with by using a thick needle to push the cornea back. Islamic medicine came up with a better solution: a thin hypodermic needle inserted through the white part of the eye to extract the obstructing cataract material.

The illustration above is from a later manuscript copy in the Trinity College Library of Roger Frugard's Practica Chirugia that has many illustrations that help explain his techniques. Let's learn a little more about him and them tomorrow.

About Preventing Children

Folk in Classical and Medieval times developed many methods for avoiding getting pregnant, but sometimes the inevitable happened. The Bible's statement to "be fruitful and multiply" made the Church's stance on aborting a pregnancy clear, but the rest of the culture did not always see it that way.

Avicenna (c.980 - 1037) offered this reasoning:

At times it may be necessary to induce abortion; that is, when the pregnant woman is young and small and it is feared that childbirth would cause her death, or when she suffers from a disease of the uterus or when a fleshy growth in the uterus makes it very difficult for the fetus to emerge. Also when the fetus dies in the womb of the woman. Know that when labour continues for four days it means that the fetus is already dead.

Methods of abortion could be dangerous to the women as well. Hippocrates had refused to use abortifacients because of the danger they posed to the mother. The early Church stated that women who abort a child should be exiled from the church. A synod in 314 modified that to 10 years of exile. The Church Father Basil the Great later softened that, saying it should be less if the woman shows repentance.

In another case, a woman was sentenced to death for aborting her child precisely because she did it with malicious intent to prevent her husband (whom she had come to hate) from having an heir. Roman law allowed that, if a woman were to do the same thing for the same reason but it post-divorce, then she should only be exiled.

The Church Father St. John Chrysostom criticized abortions, but gave the example of a sex worker who needed to abort a pregnancy or else she would lose her livelihood. He goes so far as to blame her male client, who was responsible for getting her pregnant, as the real murderer.

A 9th century Byzantine author of a biography of a Greek Patriarch Ignatios tells the story of a woman with a breech birth who is in intense pain. The doctors prepare for an embryotomy (removing the baby by cutting it into parts and removing them). The 6th-century Bishop Paul of Mérida, who trained as a doctor in his youth, doesn't scruple to perform an embryotomy to save a woman's life.

That late-term abortions can find their way into accounts of religious lives and can be justified by Christian saints suggests a very different attitude toward the health and safety of the mother than is sometimes taken these days.

Embrotomies would have been difficult for the surgeon and the patient. Let's talk next about some of the other surgical practices that were employed in the Middle Ages. 

Avoiding Pregnancy

Yesterday we talked about medieval parents having large families. Today we're going to talk about preventing large families. Although Canon Law insisted that sex was solely to be engaged in for procreation, in the "real world" that was not a feasible attitude. (Pope Gregory IX even stated that marriages entered into intending not to have children were ipso facto null.) There were, therefore, plenty of instances where becoming pregnant was not a desirable outcome of sex. Therefore, methods were devised for avoiding pregnancy.

The simplest one was for the woman to track her menstruation. Lack of menstruation could lead to pregnancy, so either knowing reliably when menstruation would occur or inducing it was one method. Herbal remedies were often readily available around the house as prophylactics against pregnancy. Parsley, Queen Anne's Lace,* and Pennyroyal were considered effective in inhibiting fertility.

Another way to prevent pregnancy was by inserting something into the cervix. Lacking modern IUDs, Avicenna's Canon of Medicine suggests mint "in there" would prevent conception. Aristotle taught that rubbing the womb with cedar oil, lead ointment or incense, mixed with olive oil, would prevent the sperm from coming in contact with the woman. (The lead ointment had other damaging effects.) Also, wooden blocks were not uncommon, and very uncomfortable.

One could try to prevent the sperm from reaching its goal through a barrier, or one could try to kill the sperm. Medieval and Classical spermicides included inserting a cloth after the act that was soaked in vinegar, or honey, or grated acacia leaves soaked in honey (the sap in acacia is spermicidal).

Another way to "avoid pregnancy" is to pretend one is not pregnant. I grew up understanding the meaning of the phrase "she's gone to her sister's" to explain a long absence.

A French novel (only a little later than the Middle Ages) has advice to a teenage girl about sex, and assures the girl that getting pregnant unexpectedly is easily managed, but not by abortion:

...moreover, to remove any worry, there is one more thing to consider, it is that this mishap is not so extraordinary that one should fear it so much. There are so many pregnant girls who never attract notice, thanks to certain corsets and dresses made to order, which they use, and which do not prevent them from having a good time with those who made them pregnant.

...and during that interval, you can simulate illness, trips, pilgrimages. When the time comes, you will identify a midwife who is obliged in conscience to keep the fact hidden. [L'Escole des Filles]

If the calendar was off, if contraception didn't work, then eliminating the fetus was the next step, but we'll look at that grisly topic tomorrow

*The name is for Anne, Queen of Great Britain (1665 - 1714); earlier names would have been "bishop's lace" or "bird's nest" or simply "wild carrot."

Hair & Baldness

Let's talk about hair in the Middle Ages; not hairstyles, but hair itself.

Hairstyles were important, of course, because there was cultural significance to them. A tonsure shaved the head of a monk to resemble the Crown of Thorns pressed onto Jesus prior to the Crucifixion. (Although we believe some tonsure patterns were different.) "Hair and Religion" was a topic that produced a Part 1 and Part 2. A lock of hair from a saint was just as good a relic as a bone, and for a long time was the only thing allowed to be taken from the body. And it was felt that a shaved head disqualified a man to be king. Charles the Bald was probably not bald since he was qualified to be emperor, and the nickname was likely a reference to something else.

But what did the Middle Ages feel about hair itself? Well, they liked it, and if you were a man who didn't have it on the top of your head, you'd probably want to find a way to get it back. They therefore looked for remedies for baldness. One Irish manuscript authored by Connla Mac an Leagha assembled 920 remedies arranged from the head to the feet. Several are remedies for hair-related conditions (I'll skip over the lice and mites solutions).

Connla said hair could be encouraged to grow with a poultice of crushed chickweed and goat's dung. No details are included regarding proper preparation—which suggests that the readers would be familiar with it and did not need instructions—just that it needs to be applied and then held in place with a cloth. (My personal assumption is that no one in his right mind would smear goat dung on his head, and therefore the uselessness of Connla's remedy would never be discovered.)

Another slightly more elaborate hair-loss cure also included dung (I see a pattern forming). Meadowsweet, plantain, sheep's fat, and fresh butter were mixed with sheep's dung. (Must have fresh; wouldn't want it to spoil and stink up the sheep's dung.) These were to be cooked together and then strained (and presumably cooled) and applied to the scalp. It probably became a semi-solid thanks to the butter, so it would stay on the head when applied.

Another way to make a vile cure for baldness was to fill a clay vessel with mice, seal it with a lid, and bury it for a year. When the year was up, dig it up and open it, and smear the results not the scalp. This was considered so powerful a remedy that it was advised to wear gloves when handling it, lest you grow hair on your fingertips.

It wasn't all about baldness: one might also lament the graying of the hair. We know oak galls were used in making dark ink. Hot water, powdered oak galls, and the juice of white cabbage were mixed together, (presumably) cooled, and then applied to the graying hair and a cabbage leaf put on top of the process. This was supposed to reverse graying.

An old friend, Hildegarde of Bingen, wrote about medicine as well as music. She had ideas about hair and its lack:

A person with a big, wide bald spot has strong warmth inside himself. This warmth and the sweat from his head push out the hair. The moisture of his breath is fertile and moistens the flesh where the beard grows so that much hair can grow there. But a person who does not have much hair in his beard, though hair in abundance on his head, is cold and quite infertile. When his breath touches the flesh around his mouth this flesh becomes infertile.

And she also had a solution for hair loss:

When a young person begins to lose his hair, take bear fat, a small quantity of ashes from wheat straw or from winter wheat straw, mix this together and anoint the entire head with it, especially those areas on the head where the hair is beginning to fall out. Afterwards, he should not wash this ointment off for a long while.

Researching for this post led me to information that prompts me to write a "Hair and Religion, Part 3"; I'll get right on that for next time.

John of Salisbury on Skepticism & Medicine

John of Salisbury liked the idea of academic skepticism, which ultimately came from Plato's Academy. Let me explain. The head of Plato's Academy post-Plato was Philo of Larissa, who fled Athens for political reasons and landed in Rome. While there, Cicero (106 - 43 BCE) attended some of his lectures and learned "academic skepticism." This started with Socrates' method of posing a series of questions to someone that could undermine their firmly held beliefs. Cicero's writings were known to John of Salisbury's time, but the Greek influences not so much.

John's approach was one of "moderate skepticism": although some things could be proven "definitively" there was still room to question them. He prized the use of Rhetoric and Grammar to challenge ideas, which put him at odds with some scholars who rejected the Trivium because Grammar and Rhetoric (they felt) clashed with the third part of the Trivium, Logic.

John considered the Trivium crucial to human beings because he felt philosophical thought was the dividing line between human beings and wild animals (and human beings and less intellectually gifted human beings). The arts of the Trivium were what enabled philosophical and critical thought to contribute to the ability to socialize, to create a community, and they therefore enabled human well-being.

He had very strong opinions on the state of medicine, believing that doctors had become more interested in making money than researching the best way to care for patients. Some physicians focused on the state of the soul and its relationship to bodily health. John thought this was ridiculous since there was no way to test or prove anything involving the soul. It also "trespassed on religious belief" which he was not keen to support. He expressed that doctors should spend their time divided evenly between research and practice, because the two pursuits were currently separated and leading to two separate practices that did not support each other. He proposed what he called regularum compendium: figure out what caused the illness, figure out how to cure the illness, figure out appropriate aftercare, then figure out how to avoid the illness in the future.

There was another Latin phrase that John of Salisbury coined that influenced later times, theatrum mundi, and we'll look this topic tomorrow.

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.