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.

Medicine Men

In the middle of the 14th century, the centers of medical knowledge were the universities at Bologna, Montpellier, and Paris. One of the professors linked to Bologna who trained several future doctors was Taddeo Alderotti.

Alderotti was born in Florence but moved to Bologna where he taught several men like Gentile da Cingoli, the emperor's doctor Bartolomeo da Varignana, and the anatomist Mondino de Luzzi.

Alderotti was a highly reputed doctor in his own right, and patients came from all over Italy to see him, making him a very wealthy man.

Another student at Bologna was Henri de Mondeville. Mondeville (c.1260 - 1320) was French, and studied at Montpellier and Paris before moving to Bologna to study under the prominent surgeon Theodoric Borgognoni, who had some new ideas about treating wounds. After studying under Borgognoni, he went back to the University of Montpellier as a professor of anatomy and surgery. He became royal surgeon to King Philip IV and his son King Louis X.

Mondeville wrote the first French surgical treatise, La Chirurgie ("Surgery"). Intending to write it in five sections, he only completed two from 1306, when he started, to his death in 1320. Some of his statements were opposed to current "wisdom," and it wasn't until centuries later that it was rediscovered in 1892 and Mondeville's ideas were justified.

What was so controversial? His approach to treating wounds, which he learned from Borgognoni. I'll explain the radical ideas of Theodore Borgognoni next time.

Mondino de Luzzi, Anatomist

Successful surgery benefits from knowledge of the body's interior, and the study of anatomy was not always easy to come by. Dissecting human bodies fell out of favor after the Classical Era. One Italian physician did extensive research in anatomy and restored the study of it. His name was Mondino de Luzzi, and he lived and worked in Bologna from c.1270 - 1326.

His father and grandfather were pharmacists, and his uncle taught medicine. Mondino himself taught medicine and surgery at the University of Bologna from 1306 to 1324. In 1316 he published an illustrated manual of details of the inside of the human body (sample to the left). The Anathomia corporis humani ("Anatomy of the human body") was the first of its kind.

He theorized a hierarchy of body parts based on what he considered most important. The abdomen was the "least noble" part of the body, and so should be dissected first. The thorax came next, and last was the head with its "higher and better organized" structures (the organs of the senses: eyes, ears, mouth). He also discussed different methods of dissection between simple versus complex structures, like muscles and arteries versus eyes. When dissecting muscles, he suggested letting the cadaver desiccate, rather than mess with a decaying cadaver. The Anathomia was a manual to explain Mondino's proper methods for dissection.

That doesn't mean he was right about everything. He claims the liver has five lobes, the stomach is round and its internal lining is where sensation happens and the external layer is where digestion takes place. He apparently never found an appendix in a cavern, even though he examined many intestines. He says the heart has three chambers, not four. Still, the text became a standard in medical knowledge for 300 years.

Mondino wasn't much interested in pathology of disease, which is just as important to medicine as understanding how the physical; body works, if not more so. Fortunately, there were others—contemporaries of Mondino's, in fact—of whom we shall speak...tomorrow.

Surgery in the Middle Ages

The Middle Ages saw illness as an imbalance in the humors of the body. Sometimes that could be treated by changing the diet. In the case of some illnesses, it might be determined that the body had too much of the "hot, wet" humor, blood, for which the treatment was to drain some of it.

Blood-letting was the simplest surgical procedure, but medieval surgeons were eager to accomplish more. Part of the history of surgery in Western Europe was tied to the needs of warfare. Consider John Bradmore's efforts to remove an arrow from Henry V. Another surgeon connected to royalty was John Arderne, the expert on a very particular and painful physical problem that he treated with surgery.

Monasteries and other religious organizations were more educated than the general population, and their access to books meant knowing more about medicine. There was one branch of medicine they avoided, however, even though the Egyptian and Greeks practiced it: dissection and surgery. The church was squeamish about surgery because it shed blood (and could lead to infection and death). The Fourth Lateran Council of 1215 prohibited clerics from surgery or any practice that shed blood. Dissection of corpses was also frowned on.

Lay people, however, continued to expand knowledge of anatomy. The Italian Cronica of Salimbene di Adam (1221 - c.1290) tells the story of an epidemic that was killing men and chickens. A physician of Cremona discovered through dissection that the chickens had abcesses in their hearts. The corpse of a human victim was dissected; the same abcesses were found. The physician put out a pamphlet warning people against eating chicken or eggs, assuming that they were causing the spread of the disease.

Italy was where great strides in anatomy and surgery took place. The Anatomical Theatre of Padua, begun in 1595, was the first permanent anatomical theater in the world, where students watched their teachers dissect bodies to learn human anatomy. Anatomical dissection in Italy had begun long before that, however. For that story, we have to look at Italian physician Mondino de Luzzi (c.1270 - 1326), and the Anathomia corporis humani of 1316. We'll look into him next time.

Humorism

Trying to understand biology had many false starts. You probably have some idea of "humors" and the adjectives cold, hot, wet, and dry. These four provided a nice symmetry, and as you can see in the illustration, they also fit with the foursome of elements.

Other cultures came up with different paradigms. Indian Ayurveda medicine believed in three humors (tissues, waste, and dosha, "that which can cause problems") and five elements (adding "space" to the four seen here).

These qualities were supposed to explain the functioning of the body as a balanced mixture. An unhealthy state was the result of the balance being thrown off, the excess or absence of one of the humors.

The arrangement familiar to the West likely started with Hippocrates (although there were others around his time who also expressed ideas about the four elements), who systematized the idea of different substances being balanced in humans:

The Human body contains blood, phlegm, yellow bile, and black bile. These are the things that make up its constitution and cause its pains and health. Health is primarily that state in which these constituent substances are in the correct proportion to each other, both in strength and quantity, and are well mixed. Pain occurs when one of the substances presents either a deficiency or an excess, or is separated in the body and not mixed with others. [On the Nature of Man, attributed to either Hippocrates or his son-in-law, Polybus]

Galen furthered this theory, tying it to seasons and stages of life. For instance, a child corresponded to spring. Blood was hot and wet, which corresponded to spring. Yellow bile, hot and dry, corresponded to summer, corresponding with the life stage of a young man, and so on.

The humors could also influence personalities; one Greek text put it thusly:

• 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 people who have yellow bile are bitter, short tempered, and daring. They appear greenish and have yellow skin.
• The people who are composed of black bile are lazy, fearful, and sickly. They have black hair and black eyes.
• Those who have phlegm are low spirited, forgetful, and have white hair. [from link]

These attributes were not predictive, like astrology. If a person's manner changed, it could be because the mix of humors in him had changed.

Humorism, or humoral theory, "explained" so much about physical health and temperament for 2000 years. The 1600s brought more exploration via surgery and the use of microscopes to better understand the function of the organs of the body and the fluids inside it. With the advent of germ theory, proposed in 1546 and expanded in the 18th century, the idea of humors fell by the wayside. 

Of course, there was much more to medical treatment in the Middle Ages than just fiddling with the balance of humors. Sometimes you had to get out the knives. Let's talk about medieval surgery tomorrow.

The Maintenance of Health

The modern Italian word for a notebook is taccuino. It comes from the medieval (and later) popularity of the Tacuinum Sanitatis. That name is a Latinized version of the Arabic Taqwīm aṣ‑Ṣiḥḥa ("Maintenance of Health"). It was written in the 11th century by Ibn Butlan of Baghdad, a physician and Christian theologian during the Abbasid Era.

The original was organized in synoptic tables: a way to present data in a simple and condensed manner, previously used for astrological tables. Ibn Butlan used them to present not just ways to treat illness and to maintain health, but also ways to prepare food and how and what to grow for health. Later manuscripts were lavishly illustrated, especially after the 14th century. (The illustration is of a facsimile edition made in 1986.)

Ibn Butlan set out the essential elements of health and well-being:

• sufficient food and drink in moderation
• fresh air
• alternations of activity and rest
• alternations of sleep and wakefulness
• secretions and excretions of humors
• the effects of states of mind

If one is not paying attention to these elements, illness occurs.

The Tacuinum includes lists of many vegetables, fruits, nuts, and herbs that are good for treating certain conditions. It also includes the dangers of excess consumption. As the manuscript was copied and distributed, changes were made, and not every copy includes every list. Some added remedies that were not in the original.

The word "humors" was italicized in Ibn Butlan's list because I wanted to draw attention to it. I've ignored discussing the medieval idea of humors for over a decade because I assumed people have already heard of them and I want this blog to focus on all the things that are not generally known. Of course, the details of humors are probably worth talking about. See you tomorrow.

Sugar!

Our teeth would no doubt be better off if this had never been discovered, but Pandora's box was opened long ago. Different species of sugarcane were being harvested in the Indian subcontinent, New Guinea, Southeast Asia, and other places long before the Common Era.

An admiral of Alexander the Great learned of sugar on a campaign in India, so it was inevitable that sugar would make it to the Mediterranean area by traders. Pliny the Elder describes it in his Natural History, but not as a food:

Sugar is made in Arabia as well, but Indian sugar is better. It is a kind of honey found in cane, white as gum, and it crunches between the teeth. It comes in lumps the size of a hazelnut. Sugar is used only for medical purposes.

Crusaders brought sugar back to Europe from the Middle East, calling it "sweet salt." It was a common sweetener during the reign of Henry II, and Edward I imported a lot. Until the 1300s, it was affordable only by the wealthiest.

Venice saw its value and set up manufacturing in Lebanon, becoming the chief sugar distributor in 15th century Europe. Sugar was introduced to the Canary Islands and Madeira, after which Europe could get it more easily (but not necessarily cheaply). In the same year that Columbus sailed westward on his maiden voyage to the New World, Madeira produced 3,000,000 pounds of sugar.

Part of the allure of sugar was its reputed health properties. The Tacuinum sanitatis ("Maintenance of Health") of the 11th century has this advice about sugar:

Ask the grocer for refined sugar which is hard, white as salt, and brittle.  It has a cleansing effect on the body and benefits the chest, kidneys and bladder...It is good for the blood and therefore suitable for every temperament, age, season and place.

If it's that good for ill bodies, imagine what it could do for a body already healthy? There was plenty of inducement to enjoy sugar for its "healthful" effects.

You might guess that the Tacuinum sanitatis—considering its early provenance—was not a European text, and you'd be right. Let me tell you more about it 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.

Saint Blaise

The man who would become known to Western Europe as Saint Blaise was Bishop Vlasi of Sebastea in Armenia. His life was written about 400 years after his death, in the Acts of Saint Blaise:

Blaise, who had studied philosophy in his youth, was a doctor in Sebaste in Armenia, the city of his birth, who exercised his art with miraculous ability, good-will, and piety. When the bishop of the city died, he was chosen to succeed him, with the acclamation of all the people. His holiness was manifest through many miracles: from all around, people came to him to find cures for their spirit and their body; even wild animals came in herds to receive his blessing. In 316, Agricola, the governor of Cappadocia and of Lesser Armenia, having arrived in Sebastia at the order of the emperor Licinius to kill the Christians, arrested the bishop. As he was being led to jail, a mother set her only son, choking to death of a fish-bone, at his feet, and the child was cured straight away. Regardless, the governor, unable to make Blaise renounce his faith, beat him with a stick, ripped his flesh with iron combs, and beheaded him.

This incident forever joined the saint's name to throat ailments, but he is also the patron saint for infants, animals, builders, stonecutters, carvers, drapers, wool workers, wool industry, veterinarians, physicians, healing, the general sick, choking, and Ear Nose and Throat illnesses.

As well as a plethora of causes for which one might appeal to Blaise, there were numerous locations that claimed his patronage: several towns in Italy, in Sicily, Sebastea, and Dubrovnik, whose Republic of Ragusa even has his likeness on their flag! Dubrovnik and others have parades and festivities on 3 February for the saint's feast day.

Blaise was very popular in the Middle Ages, with many churches and locations named for him. A shrine near where he was martyred was commented on both by Marco Polo and William Rubruck.

Outside of works on saints' lives, he was mentioned by Aëtius of Amida, a medical writer, for his healing abilities. Aëtius is interesting for many reasons, one of which is the typographical error in one of his works that named a near-universal medical issue. But that's a story for tomorrow.

The Pearl of the Adriatic

The oldest apothecary in Europe was founded in Dubrovnik, in southern Dalmatia in Croatia. At the time, it was called Ragusa; to be fair, it was called both names for centuries, "Ragusa" being used since the 10th century (it was the center of the "Republic of Ragusa") and "Dubrovnik" showing up a century later as the town name and widely used in the 16th and 17th centuries up to now. 

It was founded in the 7th century by Romans from the south fleeing fighting between Slavs and Avars. Byzantium initially protected this part of the world, but later it would fall (like much of the Adriatic coast) under control by Venice.

One of the things Ragusa became known for was ship-building; in fact, they built their ships indoors because their methods were so innovative that spies wanted to copy them.

A very forward-thinking city, they adopted a code of laws and public services that sound very modern. A medical service was started in 1301, the apothecary mentioned above was established in a monastery in 1317 and still functions today. In 1347 they opened an almshouse (just in time for the Bubonic Plague which arrived a year later), and a quarantine hospital in 1377. Ragusa established a separate town outside the walls for those suffering from leprosy. 

Their law only allowed a doctor to be paid when the patient was healed. A female doctor was mentioned in records in 1325. A service for removing garbage from the town was first recorded in 1415. The city paved the streets, and shop-owners were required to sweep the area in front of their shop. Aqueducts and sewage systems were installed in 1436. Underground silos were built that could hold 1200 tons of grain (which they had to import). They voted to abolish slavery in 1416.

Ragusa/Dubrovnik has so much fascinating history that I want to continue this tomorrow.

The Plague Continues

The Bubonic Plague, also called the "Black Death," first hit the European Middle Ages primarily in 1348-1351, but that wasn't the end. To be fair, it was revving up to the east long before 1348. It was responsible for deaths in the 1200s in China. In the 1340s it was killing people living around the Black Sea. In fact, we know that it existed among rodent populations high up in the Alps.

How do we know this?

The spread of the plague has been better understood in recent decades thanks to modern science and the sequencing of genomes. The bacterium Yersinia pestis has been sequenced, and modern science can detect it from bones of the long-dead. In many cases, those bones are easier to identify because the plague killed so many so fast that the corpses were thrown into mass graves quickly. In fact, the approach of the plague did prompt preparation: the mass graves in London were dug before the plague actually arrived. (The illustration shows a mass grave of plague victims in France.)

Therefore, by examining skeletons from different eras, we can track the spread and durability of the plague, which was endemic in Europe after the mid-14th century appearance. Plague returned approximately every decade or so for centuries. Whatever the cause (see the link in the first paragraph), folk realized they should try to stay away from those who were infected. This led to quarantining when news of a plague resurgence came to a community. You could either barricade yourself in your house or escape the town. In 1377, the town of Ragusa on the Adriatic initiated the first wide-spread, mandatory quarantine. In the second half of the 1400s, quarantines were common around the Mediterranean, whose warm weather and coastal ports allowed plague to thrive and spread.

Ragusa actually had a reputation for doctors. If you search for Ragusa on a map today, it will show you a city in southern Sicily, not on the coast of the Adriatic. That's because it's got a different name now: Dubrovnik. Let's talk about its medieval history tomorrow.