14th Century Health
As population of medieval towns and cities had increased, hygienic conditions had worsened, leading to a vast array of health problems. The medical knowledge of the time was limited and despite the efforts of medical practitioners and public and religious institutions to institute regulations, medieval Europe didn’t have an adequate health care system. Antibiotics wouldn’t be invented until the 1800s and without them it was nearly impossible to cure diseases. There were many myths and superstitions about health and hygiene then as there still are today. Many people actually believed that disease was spread by bad odors, and it was also assumed that the diseases of the body resulted from sins of the soul. No matter if you were of the aristocracy or the peasantry, sometimes even the best medical care couldn’t fight some things off, such as the plague. Not only was illness a cause for short life spans but accidents and injuries also were responsible.
The majority of people had believed that the plague had been sent by God and a large amount of people had also believed that it was a punishment for their sins. The medical knowledge of the time was insufficiently developed for any effective treatments of the disease. Many doctors had believed that it was due to a ‘miasma’, pollution of the air with toxic matter from rotting materials. One good thing about the plague was it did prompt a few attempts at cleaning up and providing better hygiene. Even the King of England sent a protest at the filth in London’s streets, people were afraid of catching the illness from affected corpses. However, the protest didn’t tackle the root cause of the plague, rats and fleas. Some people had sought for answers, turning to astronomy and blaming the conjunction of the planets.
The black death victims in the Middle Ages were absolutely terrified of the deadly disease. It held massive mortality rates of between 30 and 40 percent. Victims would have no idea what had caused their illness or death, and physicians didn’t either. The most that could be done was the trying out of various concoctions of herbs that were administered to relieve the symptoms, there was no cure. Headaches were relieved by rose, lavender, sage and bay. Sickness or nausea were treated with wormwood, mint and balm, lung problems with licorice and comfrey. Vinegar would be used as a cleansing agent as it was believed that it would kill diseases. Bloodletting was commonly thought to have been one of the ways to treat the plague. The blood that had exuded was black, thick and absolutely vile smelling with a greenish scum that mixed within.
The black death was treated by lancing buboes and applying a warm “salve” of butter, onion and garlic to them. Various other remedies were tried as well, including arsenic, lily root and even dried toads. During the later part of the plague outbreak, in the Elizabethan era, substances like tobacco had been brought from the New World and were also used in experiments to treat the disease.
Natural functions, like sneezing, were thought to be the best way of maintaining health. When there was a build-up of any of the humors, or body fluid, could be disposed of through sweat, tears, feces, or urine. When the natural systems had broken down, illness would occur. Medieval doctors would stress prevention, exercise, a good diet, and a good environment. One of the best diagnostic tools of the time was the uroscopy. The color of a patient’s urine would be examined to determine their treatment. Other diagnostic aids would include pulse and collection of blood samples. Treatments would range from administration of laxatives and diuretics to fumigation, cauterization, and taking hot baths and/or herbs.
Surgeries would also be performed, but only as a last resort. It’s scary to think about a surgery being done back then, but there were successful cases of surgery of breast cancer, fistula, hemorrhoids, gangrene, and cataracts, even tuberculosis of the lymph glands in the neck (scrofula). The most common surgery though was bloodletting, and was meant to restore the balance of fluids in the body.
Some potions were also used to relieve pain or induce sleep during a surgery, but were themselves potentially lethal. One of these potions had consisted of lettuce, gall from a castrated boar, briony, opium, henbane, and hemlock juice. The hemlock juice would easily have caused death.
Many people had looked for relief from their illnesses through meditation, prayers, pilgrimages and other non-medical methods. The body was also viewed as part of the universe, a concept that had been derived from the Greeks and Romans. The four humors, as I had written about in the blog about the 13th century, were thought to be directly related to the four elements. In order for one to be healthy they had to have all four of the humors in balance. Too much of one was thought to cause a change in personality. An example of this would be if one had too much black bile it could create melancholy. University-educated physicians subscribed to this humoral theory of illness and would strive to treat diseases first by placing it within its appropriate intellectual framework and then they would balance the humors. Quite often, to balance out humors and cure a patient, purgatives and enemas would be used. It was even thought that an individual’s susceptibility to the plague had stemmed from their personal imbalances within the humors.
Medicine was often a risky business. Bloodletting was a popular method to restore a patient’s health and their “humors”. Early surgery had often been done by barbers without any anesthetic, which had to have been excruciating. Medical treatment was available mainly to the wealthy, and those that lived in villages had rarely had help of doctors who had practiced mostly in cities and courts. Remedies were often herbal in nature, but would also include ground earthworms, urine and animal excrement. Many medieval medical manuscripts had contained recipes for remedies that had called for hundreds of therapeutic substances. The notion that every substance in nature had held some sort of power accounts for the enormous variety of substances.
Many treatments had been administered by people that were not involved in medicine. The coroners’ rolls from time to time reveal how lay persons would often make sophisticated medical judgments without the aid of any medical expert. It is from these reports that we also learn about some of the major causes for death. Other “doctors” ranged from herbalists and conjurers, to surgeons and university-trained physicians.
Though there were some differences between the medical training in Oxford and in Europe, they were very similar. Their emphasis would be placed on theology and liberal arts for the first seven years and then an additional three years of study to obtain a “MD Degree”. Liberal arts training would include the trivium of grammar, logic, and rhetoric, and a quadrivium of mathematics, music, geometry, and astronomy. The trivium also reflected on reasoning, discussion and debate, all of these were skills that were thought to be the most important to be learned. Further medical training was largely provided by certain texts, mainly by the classic medical authors of Avicenna and Galen. Some universities would also require clinical training with a physician, which would have to be arranged by the student. Some schools would even require the attendance at an anatomical dissection. The basis of becoming a physician would rest on a student’s ability to know the reasons for sickness and to know how an illness had fit into an intellectual theory about health. It was this intellectualism that would be critical in distinguishing “the learned physician who knew the reasons for things [from] the hireling with a knack for healing”. Many physicians at the time would take holy orders of some sort.
Surgery was distinctly separate, and for the most part, was a lesser craft and was not widely practiced by physicians. This was partially because manual labor was necessary to perform it, as well as because of the blood loss that was inherent to the process. At one point a papal bull had forbid clergymen from shedding blood for any reason, including surgical procedures.
In the 13th century, Theodoric Lucca had written “Every day we see new instruments and new methods [of removing arrows from wounded soldiers] being invented by clever and ingenious surgeons”. One man in particular had stood out in the field of surgery, William Saliceto. He had helped set up a school that would be dedicated to surgery. William also one of the first people to realize that pus on a wound had been a bad thing, and recommended using a knife to perform surgeries instead of cautery. In the later years of his techniques, he had even managed to stitch together severed nerves.
There were also a few skilled medieval surgeons that were known to have been able to perform operations on many external problems, such as: facial ulcers, removal of teeth and eye cataracts, and also some internal ones too, such as: the removal of bladder stones. However, despite their advances the history of surgery was still barbaric compared to our modern standards, and they would lose a lot of patients due to infection as they didn’t know that an unclean environment would also cause problems. Even though they had a certain level of skill, the butcher-surgeons were still bound by the Christian beliefs at the time. One common technique that had been used by these people was their cure for epilepsy, which was known as trephining. It would involve the removal of a piece of the skull in order to let a demon to escape through the hole that was created. The Muslim doctor, Usama ibn Munqidh had written back in 1175:
“They brought to me a knight with a sore on his leg; and a woman who was feeble-minded. To the knight I applied a small poultice; and the woman I put on diet to turn her humour wet.
Then the French doctor came and said, “This man knows nothing about treating them.” He then said, “Bring me a sharp axe,” Then the doctor laid the leg of the knight on a block of wood and told a man to cut off the leg with the axe, upon which the marrow flowed out and the patient died on the spot.
He then examined the woman and said, “There is a devil in her head.” He therefore took a razor, made a deep cross-shaped cut on her head, peeled away the skin until the bone of the skull was exposed, and rubbed it with salt. The woman also died instantly.”
In an attempt to discover ethical codes through history for the medical field, some ethicists have proposed at least three conditions that are necessary for the development of a duty-to-treat. First, a physician would have to had to recognize that they were at risk of also becoming infected. The theories of contagion and polluted air as a causative of diseases were present during these times and had given a rise to prescriptions of strong smelling herbs and fumigation with pungent woods, as a way to ward off such things as the plague. The theory of infection and identification of microorganisms wouldn’t come until many years later. The lack of effective treatments, physicians would recommend personal hygiene and well-being as cornerstones for prevention, with an emphasis on dietary prescriptions to balance out the humors.
Second, was the establishment of a professional ethical code for epidemics that required an organized profession of medicine. With multiple unlicensed practitioners, the practice of medicine during the mid 14th century was far from being organized, the cohesive medical profession that we now know in our world today, just simply did not exist in the Middle Ages. Brewers would practice surgery, abbots delivered babies, and friars would write medical books. The chancellor of exchequer who had doctored the king was a Cisterician surgeon, all of these people were involved in healing and all were involved in other pursuits at the same time. While the Hippocratic Oath was certainly known to the medieval physicians, there is little evidence that it had substantially influenced their practice. The Oath didn’t set forth any ethical principles for the event of an epidemic but it focused instead on patient/physician relationships. Even these principles were not universally acknowledged.
During the plague years, prevailing wisdom was simple, “flee early, flee far, and return late”. It has been noted that some kind of duty-to-treat ethic had existed at the time, but it had stemmed from powerful Christian virtues of charity and service to the poor, rather than from a sense of professional obligation. These sentiments are echoed in Henry of Lancaster’s “Book of Holy Medicine”, as he consistently appeals to Christ as the physician to heal him: “To you, [most sweet Lord] Jesus Christ, I come as to a doctor”.
Thirdly, a public expectation of duty-to-treat is necessary for an ideal to take hold. There must be a “social contract” between a physician and his patient, or even a physician and the society he lived within, for such a duty to treat to exist. There is little evidence that such a social contract did exist during the Middle Ages. What little expectation there might have been would have likely centered around the notion of Christian duty to treat the sick. The history of the medieval plague years throws into stark relief the ethical vacuum that doctors of the time had to fill on their own, falling back on religious convictions, personal compassion, or pragmatic concerns for self-preservation as a basis for their actions. Public expectations of the physicians during epidemics are, even to this day, a point of some contention, with few explicit guidelines on a physician’s duties during such a time.
The church also had a lot to do or say about medical ideals of the time. They had forbid human dissections and would encourage people to look to prayer for healing. People had agreed blindly with a lot of what was said in the writings of Galen, a second century Roman doctor, who had said that it was largely on the battlefield that butcher-surgeons had learned their trade. The Church that first brought about hospitals to care for the sick and dying, and Galen’s teaching was exceptional for the time, but not always accurate.
Even though there were a few universities in Europe at this time most learning had happened would do so in monasteries. Monks had believed in the need for divine intervention for healing the sick. They would tend to see illness as a punishment from God, or even demonic possession. People were extremely superstitious back then and most had followed the authority of the Church without a question. So many had relied solely on their faith and prayer to cure themselves and their loved ones.
Hospitals also started in monasteries. The earliest hospital that we know of right now was the Monastery of St. Gall, built in 820. It was known to have been able to hold six people and had its own garden to grow herbal medicine in. The idea of hospitals grew over time and by the twelfth century many larger hospitals had started to be built across Europe, mostly being started by church institutions.
Most people in this time couldn’t afford to see a doctor, therefore they had other alternatives, one of which would be to go and see the local wise woman, sometimes a man. These people were skilled in prescribing herbal medicines. Their knowledge would have been handed down from one generation to another in what herbs had cured which illness. They also would act as midwives to their community and healing people was often associated with magic. By the latter part of the middle ages, a dark time in women’s history, the local wise woman healers were being associated with the devil and many were put to death for witchcraft as well.
Midwives were important to a woman’s life and health prior to the professionalization of medicine. The medical knowledge and understanding of people at this time had relied on the Roman and Greek understanding of medicine, specifically Galen, Hippocrates, and Aristotle. These medical minds had avoided women’s health issues, specifically pregnancy, because they had believed that women should handle women’s issues. William L. Minkowski explains:
“men believed their dignity and self-esteem were diminished by the manual nature of care for the pregnant patient.”
Myriam Greilsammer notes that:
“society’s reluctance to let men deal with women is largely bound up with the taboos surround the ‘secret’ parts of their bodies,”
the prevalence of this mindset had allowed women to continue the art of midwifery through the medieval era with little or no male influence on their affairs. Minkowski also wrote that in Guy de Chauliac’s 14th century work “Chirurgia Magna”, “he wrote that he was unwilling to discourse on midwifery because the field was dominated by women.” However, changing views of medicine would end up causing the women’s role as a midwife to be pushed aside as the professionalization of medical practitioners had began to rise.
Most midwives came from the lower classes and were also illiterate. Monica H. Green writes that “if midwives were literate, it seems to have been coincidental rather than a prerequisite of their work”. She also notes that unlike “female surgeons and barbers…[midwives] do not seem to be regularly married to men in the medical trades.” During the later part of the middle ages a few books would be written to teach midwifery to both women and men. Before this time, manuals were not written by practitioners or their teachers but by those who knew medical theory or some outdated information. Therefore, midwives would learn their craft from other women and from having children of their own. From time to time, as young girls they would be present at the births of their other siblings and would’ve been able to see what was supposed to be done during the birthing process by another midwife or other female family member. Men were not allowed to have viewed the birthing process at this time. Greilsammer notes the Belgian historian Louis Theo Maes’ record of a 15th century fine:
“One Henne Vanden Damme, for having hid behind a staircase to eavesdrop upon his wife, she being in labour of childbirth, which thing doth not befit a man, for the said eavesdropping was fined 15 livres.”
Women of the poorest of classes were typically helped by women in their family and their neighbors more than they were by midwives in town. Within towns and cities, midwives were more prevalent which had placed a lot more emphasis on reputation. Minkowski elaborates on this saying “many midwives served communities in a semiofficial capacity, delivering newborns, guarding access to their profession, such as a tax-exempt status or a small pension.”
Starting in the early part of the 14th century, town officials would record some midwife activities in the municipal account books. In some more exceptional situations, the midwife had a much respected reputation that may also had served as a court midwife. The women practicing this craft wouldn’t participate in guilds or attempt to organize themselves on their own, like the male medical practitioners had. Green writes that such an organization and “licensing”, which apparently had started in the mid-15th century. The earliest known example of this is from Regensburg in 1452. This “licensing was imposed on midwives from the outside, either by local municipal or ecclesiastical authorities, or by both”.
Minkowski writes that throughout the late Middle Ages, “the medical community throughout Europe was organizing into a strict hierarchy, with male doctors at the top”. Greilsammer also notes that in the early 15th century, towns had introduced “laws aimed at regulating the professions and incorporating midwives within official structures. In principle, the aim was to prevent the delivery of an infant by unqualified people or charlatans”. Greilsammer further notes that “Brussels was, in 1424 the first town in Europe to enact detailed regulations regarding the functions of midwives,” with “similar measures…enacted in Bruges in 1509 and in Mechelen in 1536”. The regulation of midwifery was also an ecclesiastical concern. “By the 14th century legislators from dioceses in central and eastern regions of northern France were issuing instructions about how to baptize correctly specifically to midwives”, writes Kathryn Taglia. She reflects, “the increasing interest that ecclesiastical authorities showed in pastoral care and the education of clergy and laity”. The laity’s understanding of the sacrament of baptism was, “the one sacrament in the Middle Ages that could be performed by anyone—cleric or lay person, man or woman”. Such an ecclesiastical and secular regulatory introduction, Greilsammer says led to a “reduction in the status and role of the midwives” that “was part of a more general degradation of attitudes toward women, and women in command of some knowledge and power in particular”. He also states that this change in perception can “be placed in its urban context and related to the general decline in women’s employment throughout Europe at the end of the Middle Ages”. These such developments had forced many of the midwives of the time out of the craft and were then replaced by men.
The timing of these regulations, as Green notes, coincided with the first stirrings of an early wave of witch persecutions, prompting several theses that had argued for a direct connection between two phenomena. Many other historians have engaged in what Taglia describes as “the debate around the issue of witchcraft and midwives”. On one side of this issue, Minkowski writes that “there is little question that Western European countries shared a deep concern for the potential of witchcraft practice by midwives,” elaborating that “by the late Middle Ages, the church and civil authorities mandated close supervision of midwives, as expressed in required professional and religious instruction and in oaths that explicitly renounced past and present resort the black arts”. Recent research of the ointments that were used by the midwives in the 14th century has shows that the women then were expert herbalists. In order to argue this, accusations were made of witchcraft that would target the knowledge of folk medicine that these women had.
On the other side of this issue, Taglia has argued that the ecclesiastical legislation in France had referenced childbirth midwives had come not out of “concern about midwives performing” witchcraft, but due to legislators’ “concern over whether midwives understood when to perform an emergency baptism and how to perform one”. David Hartley has noted that “although the midwife-witch can be found in the writings of some demonologists, influenced by the malleus Maleficarum, in few of the vast numbers of trials were midwives accused,” arguing that “a few spectacular cases have been mistaken for a general pattern and midwife-witches have been seen where none exist”. After this era, midwives would become more structured and professionalized due to the influence of legislation passed during the later parts of the era and influenced the medical profession. Over some time, midwifery would become the profession that we know it as today.
While Europe had lost most of its medical knowledge that had been passed down by the ancient civilizations, the Muslim world had retained a lot of it. Therefore, they were far more advanced than their counterparts in the west. This had ended up benefiting the European doctors because ancient books would, at times, be brought to the the west. An example would be when scholars had fled from Baghdad when it was destroyed by the Mongols. Throughout the medieval period, the Crusades also helped bring Europeans into contact with Muslim doctors.
The four humors were just one of the prevailing theories about disease in medieval medicine. The idea of it was that the body had four bodily fluids: yellow bile, black bile, blood and phlegm. These would be used to analyze the state of someone’s health. The belief was that an imbalance of these fluids was the cause of many health problems so treatment was often aimed towards addressing this. This could be done in various way, including inducing vomiting, bleeding the person, or applying leeches to the skin, none of which would have much success.
Another belief prevalent at the time was that disease was carried by smell. Therefore, people would avoid anything with a bad smell, such as rotting flesh which was seen as prudent. They would avoid smells so as to protect themselves in the times of epidemics. Medieval doctors would often carry something with a nice smell with them, such as posies. They had thought that it would counteract bad smells, preventing them from catching the disease themselves.
Astrology and the stars had also played an important part in the healing process. An example for this was during the first plague epidemic. The Pope’s doctor, Guy de Chauliac had believed that it was caused by a conjunction of Saturn, Mars and Jupiter. Guy de Chauliac had also correctly deduced that a poor diet would make people more susceptible to disease.