Note from the Editor: I’m excited that I have our first (hopefully of many!) guest post to share with you and it is a fascinating topic to start with. The history of medicine (and the history of science more generally) is a captivating and important sub-field and a frequent reader-request, but also a place where non-specialists fear to tread because of the formidable demands in languages and expertise. So I am thrilled for Robin S. Reich to come and offer you all (and me) a primer on the complexities of discussing medieval medicine, presenting the contrast between its theory and practice but also encouraging us to think on the place of medicine in society.
Reich has her B.A. in History from Carleton College, M.A.’s in history from both Boston College and Columbia and is now finishing her Ph.D. in history at Columbia with a dissertation on “Materials and Science in Norman Sicily: Translation, transmission and trade in the central Mediterranean corridor” – which, if I may editorialize a bit further, is a fascinating dissertation subject if ever I have heard one! She also writes at her blog, Robin Writes, which is well worth checking out as well.
And with that, over to Robin…
When I tell people I study medieval medicine, their first reaction is usually something along the lines of “they had medicine in the Middle Ages?” It’s hard to approach medieval medicine because it is so different from what we now practice and trust as medicine, and because as a result we have a huge body of pop culture telling us that medieval medicine was utter nonsense. So not only do we have our own impressions of reading about this very foreign way of thinking, but we also have ingrained messages about the things we’re reading before we’ve ever read them. A major hurdle in approaching medieval medicine with an open mind is the idea of efficacy – did the cures we read about actually do anything, or did people spend 1000 years boiling lizards because they didn’t understand how evidence works? This is something of a bad-faith approach, because it’s trying to privilege our system of medicine over the one we are ostensibly trying to understand. The first question can’t be “did it work”, it has to be “what did they think they were doing?”
My first major foray into medieval medicine was an attempt to bypass this question altogether, and I think that same entry point helps other people too. I was interested in the Black Death, specifically how there could be a system of medicine surrounding a disease that was, at the time, incurable. I wasn’t worried about whether anything medieval practitioners were doing worked on the plague, because we know it didn’t, and, more importantly, they knew it didn’t. And yet they kept writing about medical approaches to the plague, and I had to wonder why. So I focused in on a specific author, ibn Qayyim al-Jawziyya, a jurist and physician living in Aleppo, Syria in the first half of the fourteenth century, who died about a decade after the start of the Black Death in the 1340s. He wrote a book in Arabic called al-Tibb al-Nabawi, or Medicine in the Tradition of the Prophet. The purpose of this book was to take the two major medical authorities in the Islamic world at that time – the Islamic holy works of the Qur’an and Hadith, and the works from ancient Greece and Rome such as those by Galen and Hippocrates – and make them agree on what medicine is and can do. In this book, there is an entire chapter devoted to the idea of contagion, that there are diseases that can travel from person to person. And in that chapter, ibn Qayyim uses both these types of authorities to argue that there is a bodily contagion, a literal transfer of disease, but there is also a psychological and a social contagion. These are the fear and anxiety of getting sick that can make you sick in other ways, and how you react to other people based on the belief that they can make you sick, and the harm you can cause by taking that belief too far. I was so stunned by this argument for is complexity, nuance, and wisdom. I even talked about it at the start of the COVID-19 pandemic, as a reminder that pandemics are social issues, not just medical ones. Ibn Qayyim really convinced me that medieval medicine had tremendous depth to it, and our pop culture understanding of it was superficial and unfair. So, I’m here now to try and give you a primer on medieval medicine so you can see a bit of this beautiful, confusing complexity as well.
Texts and Theories
When historians talk about medieval medicine, we’re mostly referring to the medicine reported in books explicitly on the subject of healing that were written in Latin, Arabic, or Greek from the tenth to fourteenth centuries in Europe and the Middle East. Sometimes we include texts from other languages, like Old English, Hebrew (we have a bunch of these from throughout Europe, especially Italy) or Syriac (a dialect of Aramaic used in Syria and what is now Iraq). Generally, texts from earlier periods, the sixth through ninth centuries are considered “Late Antique” and accepted as a separate tradition. We also tend to be unaware of texts from Africa, most of Central Asia, and almost all of South and East Asia. This reflects divides in our fields of study and can partially be blamed on the issue of languages. But it’s important to recognize that medicine written about in the Middle East, especially, drew a lot from Indian and sometimes even Chinese traditions, so these other traditions are certainly not irrelevant, just underrepresented.
You’ll notice that I keep talking about medical writing and medical texts. Historians have a bias towards written evidence, especially when it comes to medicine and science more broadly, I think in part because that kind of evidence is easier to interpret. We like writing and reading, it’s what we’re used to, so when we want to know about medicine we look for writings about medicine. We also do this because a lot of medieval medical texts became foundations for Renaissance-era and modern writings on medicine. In the thirteenth century, when universities began to establish themselves in places like France and England, they would put together reading lists that included specific works on medicine, and these reading lists evolved but were kept in use for hundreds of years, to the point that Avicenna’s Canon of Medicine, written in the eleventh century, was still being read in Europe in the seventeenth century as part of the university medical curriculum.
But it’s important to recognize that writing is one limited part of medicine. Even today, if you read a medical textbook assigned in a medical school, it won’t tell you much about what doctors do, because so much of their training is in their practica, their hands-on practice. In the same way, medieval medical texts don’t really tell us that much about what medieval doctors did. In fact, I argue that medieval peoples considered the actual practice of medicine inappropriate for writing – they used writing to discuss the theoretical aspects of medicine, knowing that the practical aspects were things that you had to learn in person. Extending this divide further, the people who were writing these medical texts weren’t necessarily practicing doctors. These writers were typically known as physicians, which meant people who were educated about the intellectual aspects of medicine. Practitioners were a separate category, and in many cases not very well respected by physicians. So, we have a doubly difficult time understanding what medieval medicine was, because the people who practiced didn’t write about it, and the people who wrote about medicine thought practice was beneath them.
The theory of medieval medicine most consistently centered on the theory of the four humors. It’s part of a larger systemic understanding of the world, in which all matter is made up of four fundamental elements: earth, fire, air, and water (insert Avatar joke here). The four humors are reflections of these same elemental influences on the human body, although there isn’t a direct correspondence between each element and each humor: the humors all represent blends of the elements. The humors are: blood, bile, black bile, and phlegm. Each of these humors has a set of qualities: hot or cold, wet or dry. Every individual’s balance of humors is unique, with some people having a lot more bile than everything else, for instance, and that unique balance is referred to as their complexion. This system mostly derives from the writings of Galen and Hippocrates, both Greeks of the Roman Empire who developed this system as a way of talking about the predictable actions of the body in a systematic way. Based on complexion, medical care could be suited to each patient, so the theory goes.
This so-called Galenic model or humoral theory is the foundation of medical writings within that entire large geography I described. There are some other major influences as well. Most important among these is what I mentioned earlier, the Islamic religious texts: the Qur’an, the central text of Islam that tells the revelation of the angel Gabriel to the Prophet Muhammed; and the Hadith, a collection of stories about the Prophet and his companions used to illustrate common problems and approaches to daily life. Within these texts there are many references to healing and disease, and so many Muslim physicians wrote interpretations of these references and built a further system of medicine from them. For instance, ibn Qayyim’s discussion of contagion deals in part with a particular hadith that says “there is no contagion, there is no evil portent, no ill-omened owl” – ibn Qayyim interpreted this passage to mean that one should not be superstitious, that the communication of disease from one person to another is not the same as the irrational belief that some individuals, places, or things are inherently unlucky and bring misfortune.
Medieval medical texts that set out to discuss medicine as a concept, or to describe a system of medicine, typically explain aspects of these systems. Avicenna’s Canon of Medicine is one of the most influential of these. Historians argued for a long time, up until as recently as the 1990s (and some still do) that, based on these writings, medieval medicine doesn’t really change for about 500 years, because these texts say the same things over and over. In reality, there are contentious arguments about medicine going on under the surface of these texts. A lot of them are commentaries, where the author will take an important text, excerpt quotes, and then write his* interpretation. This is a subtle form of argument – these authors rarely outright say that someone else is wrong. They are still using the same terms, but they are constantly challenging assumptions and accepted wisdom. A lot of these debates play out over specific sub-fields of medicine. For instance, there is a long tradition of the theory of diagnostics – how to assess a person’s health based on visual signs, but also based on the reading of the pulse and visual examination of urine. Even though almost every text on urine has the same title (on urines) and addresses the same topic, these texts really vary over time, as physicians argue about things like what sediment in urine shows.
(*yes, these authors were usually men, and I’m coming back to this point.)
These arguments are mostly being played out between people who write in the same language, but still over really large distances. As a result, there are some divides in written medical tradition based on language, but not so neatly based on geography. For instance, there are prominent medical writers in Spain and Baghdad who are writing in Arabic, but there are also medical writers in Spain and Germany writing in Latin, and these two conversations don’t easily overlap. We don’t really know to what extent these writers could read or were otherwise aware of conversations going on in other languages. The conventional wisdom around medieval medicine is that there wasn’t a whole lot of activity in Latin (and, by extension, most of Europe) between the 6th and eleventh centuries, and then a bunch of important works from Arabic were translated into Latin in Spain and southern Italy and that sparked a revival of Latin medicine. But I think there are a lot of problems with this explanation, and most of them have to do with the fact that writing about medicine is not the same thing as knowing about or practicing medicine. Just because a culture wasn’t writing about medicine doesn’t mean it wasn’t practicing it.
Practice and Pharmacology
Practice is an aspect of medicine that is almost entirely excluded from these writings. The idea of theory and practice as separate realms of medieval medicine goes back, once again, to Galen, who explicitly divided medicine this way in his writings. But this divide really becomes cemented in the work of Constantine the African. In the late eleventh century, Constantine translated the work of North African physician ‘Ali ibn al-Abbas al-Majusi into Latin, and he imposed a chapter system that divided the books into two sections: theory and practice. In Constantine’s translation, as in al-Majusi’s original, all the writing was about theoretical aspects of medicine – there was no description of practice. But even within that theoretical approach, there was a divide between issues surrounding how the body works (what the humors are, how they interact) and how we can know how they work (diagnostics, surgery). So, even before we get to the mechanics of doing medicine, there is already a conceptual divide between these two categories of theory and practice.
There are some medical writings in Latin that predate translations from Arabic in southern Europe that express a different branch of medicine. These are not necessarily so theory-focused – they are often collections of cures. We also have surviving Classical medical texts in Europe that didn’t need to be translated from Arabic to be available in Latin. But more compelling than any focus on writing, we have other kinds of evidence of medical practice, physical evidence.
Physical and material evidence of medical practice is a pretty big category. It can take the form of implements used in medical practice, like surgical tools, or it can be those used in pharmacology, like spoons for measuring drugs. It can be medical paraphernalia like birthing scrolls. It can be drugs themselves, surviving in shipwrecks, in evidence of human excrement from latrine pits, or in written records like pharmacists’ receipts or import records. It can be human remains, both on their own and how groups were buried. But this kind of evidence is so much more complicated to interpret than explicit writings about medicine, and it runs into new and different problems.
One example I like to turn to is about medieval leprosy. Throughout the medieval world, people with leprosy were often removed from society, placed in leper colonies or leprosaria, and approached with a combination of fear and awe. But for a long time, and arguably even still, medical historians have questioned whether medieval peoples could actually distinguish Hansen’s Disease (the modern name for the disease that causes leprosy) from other skin conditions. Because medical texts don’t make it clear that they could. Just describing the symptoms of leprosy in these limited texts, it sounds a lot like late-stage syphilis. But studies of grave sites in leper colonies show that almost everyone buried there indeed had advanced Hansen’s Disease, which is apparent in the bones, particularly the bones of the face, which develop distinctive pitting on the upper jaw and degradation of the nasal cavity. This suggests that medieval understanding of these diseases in practice was a lot more sophisticated than theoretical writings suggest.
Pharmacology is an even more complex issue, because that’s where the whole pop culture issue comes into play. Were medieval peoples really eating weird animal parts? Probably some of them. Did they do anything? Maybe, it’s not clear. We have a lot of evidence that most medical treatment was dietary. The whole humoral approach to medicine meant that medical care was largely about the maintenance of good health, not about the treatment of disease. Our system of modern medicine is more interested in curing disease than preventing it, although that is something that a lot of medical professionals are trying to change. Medieval medicine is the opposite. Pharmacological texts, pharmacists’ receipts and inventory lists, and books of cures show a lot of thought being put into how to eat right for one’s own body, and how to correct that diet as new problems arise. Now, we have to take a huge caveat to this, which is that only certain classes could actually choose what they ate. People with some degree of monetary income, i.e. people not just living on subsistence farming, had the ability to make a lot of choices about how much and what kinds of protein they ate, or whether to include imported spices or cheeses in their diets. And these were the same kinds of people who were more likely to have access to medical texts telling them what to eat, such as editions of Dioscorides’s De materia medica, one of the most consistently influential pharmacologies of the medieval world.
But a lot of medieval dietary recommendations are also about how to use local herbs or other vegetation and when. Arabic texts often dictate diets based around really common ingredients like onions, garlic, and honey. Italian ones devote most of their page real estate to common herbs like sage and laurel. These are things that could easily be integrated into the daily meals of any person of any social stratum. It’s also important to recognize that these texts might not have been instructing these lower class people what to eat, so much as taking lower class eating habits and using them to instruct upper classes. When these texts do deal with curing ailments, it’s for things like persistent stomach troubles (have some cinnamon or cumin), and not so much cancer. We have corroborative evidence that these vegetal medicines were in use, in the form of trade records, but these are also pretty limited sources – they don’t tell us everything being traded, and they don’t cover the things that could have been grown at home or picked in the wild.
This kind of practical knowledge punches a hole in the argument that medicine moved from Arabic into Latin, because we can see that medieval medicine wasn’t quite so contained, and it didn’t necessarily move in a straight line. Maybe a specific articulation of a medical idea moved from Arabic to Latin, but practices like what spices to integrate into your diet moved around in more complex and perhaps circuitous ways.
There’s a final major aspect of medieval medicine that we haven’t addressed yet, and it’s the assumption about gender. As with today, medieval medical texts assume that a patient is male – specifically, that he doesn’t menstruate and can’t get pregnant or lactate.* Female bodies are dealt with as a special aside in most medieval medicine, mostly in texts on gynecology and obstetrics. This reflects a double bias in medical writings. There is the bias I already mentioned, against practitioners, and then another bias against female practitioners in particular. Because most physicians (medical writers) were men, due to structures that educated men to write and think about theory and then gave them the option to make a living doing that, physicians don’t tend to know a lot about women’s bodies as medical subjects. As a result, we’ve gotten some pretty odd interpretations of the female reproductive system, like the wandering uterus (a theory that says that the uterus moves around the body), that treat women’s bodies as essentially ruled by unpredictability and randomness, and these don’t so much represent medical wisdom of the time as they do the limits of a specific class of educated men’s understanding of women’s bodies. We have some indications that women were typically cared for by other women, and in the rare cases that women write about women’s bodies, they convey a much more sophisticated understanding of those bodily systems than standard medical texts do. For instance, Hildegard of Bingen’s Causes and Cures (written in twelfth-century Germany) devotes almost half of its page space to a detailed monthly calendar of the menstrual cycle. We also have the Trotula, a compendium of medical cures for women from twelfth-century Salerno in southern Italy that prescribes fascinatingly mundane treatments like inserts for vaginal tightening. These and other sources that more directly report what women were doing with their own and other women’s bodies, rather than men’s theoretical suppositions about female bodies, indicate a dedicated and systematic approach to women’s medicine, but it is still hard to access what women’s healthcare really looked like and what that meant for female quality of life.
(*here I am using female and woman interchangeably, based on a medieval European and Middle Eastern dominant cultural understanding of those concepts. This is not meant to be a judgement of what constitutes gender identity, nor about the relationship between gender and sex.)
Humor and Humors
So, did medieval medicine not have any weird stuff, then? Yeah, sure it did, the same way modern medicine occasionally has weird stuff. There are instances of manuals instructing you to prepare a mineral for ingestion by cooking it in dung, or seemingly-unnecessary anal probing (although probably not actually unnecessary). What’s more, we’re getting more evidence that, yes, cures prescribed in medical manuals did actually work. The most famous one is the 2015 Bald’s Leechbook study, wherein researchers recreated an eye salve that was capable of curing MRSA (antibiotic resistant staph infections). The problem is, we still don’t fundamentally understand enough about medieval medicine, how it was practiced, and how the writings we have related to how it was practiced, to make claims about whether it was an effective system as a whole.
But there are a lot of incredible things we can learn from medieval medicine. As evidence of a society, it reveals aspects of aging, family relationships, gender, and class that we don’t otherwise get to see much of. As a medical philosophy, medieval medicine offers a counterpoint to our curative, individualistic approach, instead taking healing more as preventative and diseases more as social issues. We don’t necessarily learn about new specific cures or procedures by studying medieval medicine, although there are situations like the Leechbook example where we can, but that’s not really the point. The limitations on modern medicine are not in our ability to experiment, but in our perspectives on what kinds of methods are available. Studying a very different medical system helps us broaden those perspectives and explore new or forgotten possibilities.
There’s only one thing left: leeches and bloodletting, real or no? Real, but not what you think. Bloodletting, leeches, cupping, and cautery were all popular methods of balancing humors, but they were only practiced by the elite. Cupping has been making a comeback in recent years, and leeches never really went away. None of these were done frequently. There are mentions in rules for monastic orders about bloodletting, which suggest that bloodletting was basically an excuse to get a vacation from strict monastic life, because the multi-day recovery period saw the monk in question lying in bed, with a friend chatting all day, eating all the rich foods he normally denied himself. We also get fantastic stories like one episode from Tristan and Isolde in which the lovers try to sneak in a quickie while the king (Isolde’s husband/Tristan’s best friend) is sleeping next to Tristan in bed, after all of them have had their blood let. Tristan tries to jump to Isolde’s bed, only to burst his letting wound, fall on the floor, and start to bleed out everywhere. This wakes up the king, who is delighted to find he has caught the couple in their deception. Maybe the weirdness is not so much in medieval medicine as it is in medieval humor and romance?
Robin Reich is a (near) PhD in medieval history. She writes a blog on history in pop culture – robinwrites.blog. While her dissertation will be embargoed for the next 3 years to avoid self-plagiarism, you can find some of her work forthcoming in the collected volume Neomedievalism from University of Toronto Press and on academia.edu (columbia.academia.edu/robinsreich).