Western Europe emerged from the Dark Ages about the year 1000 in a spirit of enthusiasm, optimism, and cultural unity difficult for us to understand today, given our knowledge of the horrors, plagues, famine, war, and instability with which the Middle Ages came to an end nearly five centuries later. But in the year 1000 the future appeared bright. French culture, with its combination of faith, feudalism, and chivalry, progressively gave forth a model upon which European civilization was to be patterned, while the Mediterranean world was in temporary disarray.
Medieval philosophers, after a period of oscillation between Platonic concepts of transcendent universals (such as "Good" and "Beauty") and Aristotelian denials of their existence, ultimately sided with Aristotle, especially as interpreted by the Arabists. To them the only reality was individual reality, and the world was a pluralistic collection of individuals and particulars. Drawing upon Boethius (the Roman philosopher and translator of Aristotle through whose work Greek philosophy was transmitted to the early Middle Ages), the medieval philosopher encouraged all to "be yourself—for your personality belongs only to you!" Partly because of this strong tendency toward individuality, the rigid social stratification of a feudal society gained support, for each person had his appropriate function and position.
The Role of the Church
By the year 1200 the mendicant teaching orders of the Dominicans and Franciscans had assumed control of the intellectual life of Paris, and, as before, the Church remained a conduit for personal advancement, even in a feudal society. The first great thinker belonging to the regulares (members of a holy order living by a Rule; in contrast to the seculares) was St. Albertus Magnus (1193?-1280), who assimilated much of the Aristotelian thought imported from the borderlands of Western Christendom: Spain, Sicily, and Byzantium. The traces of neoplatonism which had survived among the Byzantine and Islamic successors of Hellenistic civilization fared poorly in Western Europe, where, nevertheless, virtually all intellectual activity remained deductive.
Near the end of the thirteenth century, Albertus Magnus's pupil St. Thomas Aquinas (1225-74) had formulated Aristotelian thought so thoroughly that it was impregnable throughout the remainder of the Middle Ages. His refusal to believe that nature abounds in unnecessary things anticipated the pronouncement of William of Occam (1300?-49) that the simplest explanation should be applied to observed natural phenomena. Having based his strongest reliance upon the eternal nature of being (essentia), Aquinas was forced to utilize a sophisticated system to explain the changes often observed in the natural world. In the same way that an acorn's nature is to become an oak, many substances have inherent potency to become something else; thus their essence would not really change but merely be fulfilled. Since no being could will itself a change for which it had no potential, all other changes must derive from some outside influence. It was here that Aquinas fell back on theology: God was the prime mover who became the ultimate source of all change in the natural world—other than the above inherently potential becoming. This doctrine of efficient causation—which became the cornerstone of Aquinas's system, known as Thomism or Scholasticism—gave the supernatural supremacy over the natural, but by implication the natural and supernatural worlds were separate if not independent. Although the brilliant synthesis of Scholasticism was to stultify independent thought during the Middle Ages, by the time Renaissance thinkers came to deny at least ordinary supernatural intervention in the natural world the foundations for the architecture of modern science had already been laid.
The earlier philosophical oscillation between a pluralistic world and one of transcendent universals also had relevance to medieval man, so that the idea of individual nation-states stood in marked contrast for him to the universality of Christendom. This discord was felt most devastatingly in Germany and Italy, where the confrontation of Holy Roman Emperor and Pope ultimately damaged both. Only on the periphery of the continent, and most notably in France, England, and Spain, was the king (or nation) able to assert authority over the Church, though only after long and bitter struggle. Individual loyalties were horizontal as well as vertical, and, in the face of an expanding Islamic world, Europe had to assume a common identity in Western Christendom. In spite of growing nationalism and the development of national languages, kings addressed each other in Latin as "brother," and the rules of chivalry maintained a common bond among the nobility of different countries. However, the Church of Rome was even more capable of crossing state lines, retaining sole authority over all who had taken holy vows. The growing power of the monastic orders led more directly to Rome than the legendary roads of the ancient Empire.
Physicians and the Guilds
In spite of a more ordered system of trade during most of the medieval period, European society remained isolated and rural, based largely on a local agricultural economy. Only the royal and noble courts were mobile, of necessity to maintain control over their vassals. Physicians trained in the universities were available only to the higher ranks of society, and for them entrance into holy orders and celibacy were generally mandatory, although, ironically, Jewish physicians (with freer access to Arabic medicine) became increasingly popular among heads of state and even popes. The masses, however, continued to rely on folk-healers, as well as barber-surgeons and teeth-pullers. Childbirth, a dangerous time for all women until the recent past, remained in the hands of midwives. Even when serious problems arose and doctors were called in, women still remained as intermediaries.
In contrast to the complex medicinal formulations of trained physicians, folk-healers relied on simpler concoctions and rudimentary magic. With the growth of cities in the twelfth and thirteenth centuries, there was an increase in the number of apothecaries setting up shop and preparing medications on their own as well as under direction of physicians. Their shops at times were meeting places for doctor and patient, but perhaps were frequented as often for astrological consultation and alchemy.
During the Middle Ages, throughout Europe, men in the same crafts and professions banded together for mutual support and to promote high standards. The old separation of surgeons from other medical practitioners was reinforced and extended by the formation of guilds which were mutually exclusive. This custom was not solely a result of the academics' disdain for surgery but derived from the medieval tendency for crafts to be drawn together by the similarity of their tools and materials rather than the purpose for which they were used. Thus, surgeons' guilds admitted barbers, and physicians were allied to apothecaries and, surprisingly, to artists because of their common use of powders (as pigments for the latter in water-, egg-, and, much later, oil-based paints). The common guild of artists and physicians may have been a significant factor during the early Renaissance in the great advances in knowledge of human anatomy, a subject of great interest to both groups.
Even though the Church retained control of the universities throughout the Middle Ages, monastic medicine declined rapidly, but only in part because of people's growing interest in receiving earthly rather than heavenly rewards. In the twelfth and thirteenth centuries, control of hospitals and infirmaries was transferred from the Church to municipalities by mutual agreement. From this time date the origins of some of the great hospitals in Europe: the Hotel-Dieu in Paris, Santo Spirito in Rome, and St. Thomas's and St. Bartholomew's in England.
The Crusades
Ironically, at the same time that church councils were forbidding the practice of medicine to those monastic orders once the mainstay of Europe, newer nursing and hospital orders were developing. The stimulus to the founding of these orders was not the need for medical care by indigenous populations but, rather, the Crusades, which ostensibly attempted the return of the Holy Land to Christian control. The Order of the Knights of the Hospital of St. John of Jerusalem, or Hospitalers, was founded in 1099. The order of the Knights of the Temple of Solomon (or Templars) and the Order of Lazarus (which was devoted to the care of lepers) were founded at the start of the twelfth century, while the Order of Teutonic Knights and the Order of the Holy Ghost were established somewhat later. These are only the most famous of a large complement of orders associated with the Crusades, and their later histories diverged widely. The Hospitalers looked after victims of the many epidemics which, we shall see, resulted in no small part from diseases brought home by returning Crusaders. The Templars, which became an increasingly military order, were ultimately subdued by the French state. The Teutonic Order, begun as a field hospital during the siege of Acre in the Third Crusade and approved by Pope Clement III in 1191, was influential in the establishment of formalized medical care in the German lands. Papal approval of the Order of the Holy Ghost (Santo Spirito) led to the founding of a hospital not only in Rome but in nearly every city of Europe. Many other Catholic hospitals were founded throughout Europe, but, unlike their monastic forebears, were almost never independent of the municipalities they were intended to serve.
The Crusaders brought home many things in addition to hospital orders. Exposure, especially of common soldiers, to the sophisticated and sensuous East created a material demand which simple piety was unable to squelch, and a flourishing trade with the East, mostly via Venice and Genoa, was quickly established. Nor did the more elaborate pharmacology of the Islamic East go unnoticed; new medical concoctions and sugar-based syrups began to appear in Europe for the first time.
Leprosy and the Plague
Disease, however, was the most significant import to Europe resulting from the Crusades. Throughout the period of the declining Roman Empire and the Dark Ages, leprosy was endemic at low levels in Western Europe, but after the Crusaders began streaming back home the number of lepers increased tremendously. During the Middle Ages, the stigma of leprosy was not restricted to the disease as we know it today but was applied to a variety of dermatologic diseases, only some of which had any degree of contagiousness. Nevertheless, all individuals called lepers were subjected to total ostracism from society, which was stringently enforced by governmental and ecclesiastical authorities, as in Biblical times. Distinctive clothing was mandatory, as was segregation in places of public assembly, even worship. However, the Order of Lazarus was so sympathetic to the care of lepers that Lazarhouse quickly connoted leprosarium, and thousands were soon built throughout Europe.
Many other contagious diseases were introduced into Europe by returning Crusaders. In spite of an elaborate system of hospices, travel in the medieval period remained arduous and risky; shipwreck, marauding brigands, and poor food added to the physical rigors. Epidemics of typhus, smallpox, and other diseases can be directly traced to returning Crusaders, but by far the most notorious epidemic to be imported from the East was that of the Black Death or bubonic plague.
Although plague had been known intermittently in Western Europe since ancient times, its reappearance in the mid-fourteenth century was dramatic and devastating. In the year 1347, the plague rapidly moved westward across India and southwest Russia. The city of Caffa (present-day Feodosiya), in the southeast Crimea, was besieged by fierce Tartars and appeared to have been saved when the invaders were slaughtered by the plague. However, to disastrous effect, the departing Tartars catapulted corpses of soldiers who had died of plague into the city. (They, too, seemed to understand the meaning of contagion). The Christian defenders may have won the day, but in traveling home nearly all died at sea. Those who did reach Italy started an epidemic which quickly spread throughout Europe (as far away as Greenland), and within a year as much as a quarter of the population of all Europe was stricken. In Marseilles, four-fifths of the inhabitants were claimed within months. Ten years after the plague struck Florence, a superb description was given by Giovanni Boccaccio, author of the Decameron:
In the year of our lord 1348, in Florence, the finest city of all Italy, there occurred a most terrible plague: either because of the influence of the planets or sent from God as a just punishment for our sins, it had broken out some years earlier in the East, and after passing from place to place and wreaking incredible havoc along the way had now reached the West where, in spite of all the means that art and human foresight could suggest, such as keeping the city clear from filth, and excluding all suspected people... Different from what it had been in the East, where bleeding from the nose suggests a fatal outcome, here there appeared tumors in the groins or under the armpits, some as big as a small apple, others like an egg. Afterwards purple spots appeared in most parts of the body... the usual messengers of death. To the cure of this disease, neither the knowledge of medicine nor the power of drugs was of any effect, whether because the disease was itself fatal or because the physicians, whose number was increased by quacks and woman pretenders, could discover neither cause nor cure, and so few escaped. They generally died the third day after the appearance without fever... The disease grew daily by being communicated from the sick to the well... Nor was it [necessary] to converse or even to come near the sick; even touching their clothes or anything they had touched was sufficient... The events and similar others caused various fears among those people who survived, all tending to the same cruel and uncharitable end which was to avoid the sick and everything that had been near them... Some felt it best to live temperately... but others maintained free living and would deny no passion or appetite they wished to gratify... And the public distress was such that all laws, whether human or divine, were ignored... [emphasis added].
Although in typical medieval fashion Boccaccio could not decide between astrological events or divine displeasure as the root evil, he and his society recognized the contagious nature of plague. He obviously also knew that in the East plague was primarily confined to the lungs (pneumonic) and not the lymph glands (bubonic) as in the West.
The general dissolution of societal restraints that resulted from total frustration and impotence in the face of forces beyond control is obvious. Throughout Europe, physicians, when available, protected themselves in elaborate garb and masks with pointed beaks in which they kept vinegar and sweet-smelling potions to counteract the stench of draining buboes and decaying bodies. In Ragusa (modern Dubrovnik), across the Adriatic from Venice, all immigrants were obliged to stay in isolation for thirty and later forty days, giving rise to the term quarantine (from "quaranta," Italian for forty).
Though by all standards the worst, the Black Death was only one of many severe epidemics to traverse Europe in the fourteenth and fifteenth centuries. In 1485 a new disease characterized by severe sweating appeared in England. Known as sudor anglicus, it brought death within days. Ironically, it was strong men who were struck down while old women and children were generally spared. A short time later, outbreaks of the "sweating sickness" appeared in northern Europe, killing many, and, surprisingly, it suddenly vanished forever.
Had contagion been the only affliction to hit Europe at the end of the Middle Ages, things would have been bad enough, but as a result of the Crusades, a growing nationalism, and an influx into the cities, societal controls were already loosening when the Black Death struck. Boccaccio's description of the total collapse of society at the height of the plague eloquently speaks for itself. Afterward, as a markedly reduced population attempted to reconstruct itself, despair and dissolution could hardly be dispelled overnight.
Famines were unusually common, and a malnourished populace was subject not only to decreased resistance to disease but also to social unrest. The tremendous strains upon nearly all the people of Europe at the close of the Middle Ages were more severe on the general population than we can easily imagine. Lacking faith in all institutions, governmental or ecclesiastic, and lacking a tradition of individual closeness with their God, many people, often in desperation, gave up entirely or thrust their futures into the hands of new intercessors. Quacks abounded. Astrology and black magic, always popular, became even more necessary to the confused and terrified masses. Pilgrimages crisscrossed Europe in hopes that certain saintly relics or special blessings of holy water might be the particular mediator of salvation. And yet, could anyone be certain of salvation?
The Saints
God, whose wrath was only too obviously expressed in disease, pestilence, famine, and civil strife, reassumed the stern visage of the Old Testament Jehovah. As the danse macabre became a subject of artistic presentation (especially in the countries north of the Alps), even Christ was depicted more often at the Last Judgment than as the Gentle Shepherd looking after his flock. Cults of the Virgin sprang up in hopes of gaining intercession with her son. Whereas in the Dark Ages intercession had been sought from those saints who were physician-martyrs of the early Church, in the Middle Ages there was a virtual explosion of cults devoted to all kinds of saints who might help cure diseases. Some, like St. Elizabeth and St. Roch, were famous for establishing healing centers or for providing medical care during their lifetimes. The popularity of these two wellborn saints was reinforced not only by the many miraculous cures attributed to them but also by their rejection of exalted station for an ascetic life of devotion to the poor and downtrodden. Elizabeth dared to treat lepers, and Roch (or Rocco, as he is known in Italy) cared for the even more dreaded victims of the plague. There are many other examples.
Most saints gained popularity during the decline of the medieval period. In contrast to physician-martyrs like Cosmas and Damian, the newer saints were increasingly associated with relief from a single disease or condition. A high degree of localism existed, and the connection of a saint to a given disease or part of the body often seems tenuous: St. Teresa of Avila was the protector of cardiac victims because an angel had shot an arrow into her heart.
At times even the individual solace offered by the Church was insufficient, and loss of emotional balance among the people of the Middle Ages led to mass panic, frenzy, and hysteria. Processions of flagellants traversed Europe with the firm conviction that their lashings reflected punishments decreed by God and foretold not only the dissolution of society but even the end of the world in the dread Day of Judgment. Another form of mass hysteria was a dancing madness called St. Vitus's dance, especially common in the German countries: men and women, generally peasants, would form circles and dance round and round frantically as if possessed until they fell to the ground, senseless and foaming at the mouth. Some historians consider the two disastrous "Children's Crusades" as further examples of mass hysteria.
Doctors and Treatment
The major developments during the Middle Ages in medical disciplines were the regulation of physicians' training and organizations, the development of ideas of contagion and policies of public health, and the establishment of ongoing institutions to provide care, if not cure, for the hopelessly ill, aged, or unwanted.
The general populace had little contact with physicians. Thirteenth-century Paris had only a half dozen doctors in public employ, with little time to spend on individual patients. Even in northern Italy and the southern German countries, where physicians were more numerous, it was rare for a sick person to have a continuing therapeutic relationship with a doctor.
The distinction "doctor" in the Middle Ages was restricted to those with high rank and academic connections who spent more time thinking about disease in philosophical terms than in providing care. When supplied with the particulars of a difficult situation, the doctor would compose a consilium, generally at a high fee, but was rarely called upon to carry out his advice. In part, this derives from the later classical period when work with one's hands was considered distinctly inferior to that of the intellect.
Diet was thought extremely important in the treatment of illness, and prescriptions would cover the minutest of details for all sorts of conditions. Perhaps greatest general reliance was placed on broths, milk, and eggs; milk alone was given especial importance in the treatment of consumption. Drugs were used heavily throughout the Middle Ages, and virtually any source might be tapped at one time or another. Plant materials were most often used in the preparation of digestives, laxatives, emetics, diuretics, diaphoretics, styptics, and the like. The most frequently used medication was theriac, which was developed in the ancient world and utilized many ingredients (one of which was viper flesh, thought especially effective against poisons). Numerous imitations, like orvietan, were also used.
Mysticism became more prevalent during the Middle Ages, even as the sciences were more heavily utilized in the development of concepts and treatment of various disease states. Symbolic procedures were thought important not only when used alone (as in the saying of an appropriate chant in the presence of a diseased individual) but even in the preparation of drugs or during surgery. Astrology was also given great weight. Furthermore, with increasing frequency during the later Middle Ages possession by devils was thought to be causally related to specific illness, generally, though not always, with psychological manifestations. For this, only one remedy could possibly be beneficial: exorcism by a priest. Mysticism, however, was extended to many other aspects of medical care. Amulets were commonly used to ward off spirits, and animal parts, especially the genitals, were thought to possess great power. Even the person of the king was thought to be of therapeutic importance, especially in the use of the "royal touch" for the treatment of scrofula (tuberculosis of the neck glands).
Surgery ultimately derived from Greek and Byzantine traditions, at least as transmitted by the Arabists and the schools of Salerno and Montpellier. In general, surgery was limited to wounds, fractures, dislocations, amputations, and the opening of abscesses and fistulas, conditions not easily ignored—at least, not for long. The procedures themselves were generally the most simple and direct possible: cut it off or out. The Arab tradition of using cautery in preference to ligation persisted. Complicated procedures for the most part were eschewed if possible, and the repair of hernias and the removal of bladder stones were uncommon. Suturing (often with human hair for thread) was known but rare. Considerable advances, however, were made in the treatment of eye diseases, as both cataract operations and the use of spectacles became more prevalent.
Although medical treatment in the Middle Ages remains for us a bizarre combination of science and mysticism, this combination was not necessarily problematic to contemporary observers and derived ultimately from a redefinition of the classical conception of humors. It didn't make much difference why there was an excess of a certain quality—or substance—in a portion of the body; it was more important to get rid of the imbalance. If an invocation or a purgative did the job, so much the better for not requiring anything more severe. But at times this would not be sufficient, and more drastic procedures were utilized. The most popular of these was bloodletting. Not unexpectedly, a physician might advise venesection but would rarely think of actually performing it. The surgeons who did this were thought unfit to receive any training beyond the obvious. Slowly, however, during the later medieval period, surgeons began to branch into two groups: those with greater education and those increasingly identified with the barbers. (It is difficult for us today to fathom the wide range of concerns allocated to barbers in the past—not just the care of locks and beard but also tooth-pulling, minor operations, the setting of bones and the like.) In France, the distinction between these two varieties of surgeons was given not only functional but legal definition.
If the pharmacy can be looked upon as the medieval workshop of the physician and of those whose vocations derived from the doctor, the public bath was the environment of the surgeon, although in the reliance of both upon diet a certain intermingling was obvious. There was much variety in the public baths. Many had tubs and vats, others often utilized steam therapeutically. Some baths were not restricted to one sex and gave bathing a notoriety which led to their being closed down. Often after a bath treatment, bloodletting would be performed, and the results were thought to be preferable to either being done separately.