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.