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Medicine in Europe and the United States

The Medieval World

With the rise of Christianity in late antiquity, medicine gave a greater role to religion; miracles became more important than enemas. Earlier medieval Christianity did preserve a certain amount of learned medicine in encyclopedias, and the creation of "great texts" gave a coherence and canonic orthodoxy to an ossified Galenism that survived into the seventeenth century. Folk or popular medicine was also incorporated into medical literature, though it is doubtful that it was practiced more widely than in antiquity. In terms of remedies, there was a great deal of overlap between popular and professional medicine. The Liber simplicis medicinae (Book of simple medicine, c. 1150–1160) by the famous healer Hildegard von Bingen provided an encyclopedia of these traditional remedies, many herbal and some fantastic, for numerous ailments.

Arabic-Islamic medicine.

During the Middle Ages the most dynamic and learned European medicine was Arabic or Arabic-Islamic, though there is little in the Koran about medicine. Arabic medicine down to the eighth century was based on popular practices using a materia medica of natural items, organic and inorganic, including camel urine as a general tonic. Urine (along with feces) was also an important ingredient of European Dreckapotheke (filth pharmacy). Greek humoral medicine, based on a secular culture, probably survived among the elite in cities of the eastern part of the Roman Empire, even after the Arab conquests. Greek medicine revived in ninth-century Baghdad, chiefly as a result of a the translation of Greek texts into Arabic. The works of Galen, the medical culture hero, became the vehicle of Hippocratic medicine in the Eastern and Western caliphates, especially in Muslim Spain.

By the eleventh century, a vast body of translations with commentaries was augmented by an original medical literature in Arabic. Arab-Islamic medicine produced remarkable summas based on a wide range of sources. As in the written history of Western medicine, historiography tends to emphasize the importance of great physicians, both for their clinical acumen and for the famous works they spawned. Among the great Persians were the philosopher-physician al-Razi (c. 865–925), a critical disciple of Galen; the prolific Avicenna, (Ibn Sina; 980–1037), author of the Canon or the medical code, a million-word everything-you-need-to-know for doctors; al-Zahrawi, who wrote a classic text on surgery (mostly cautery in Arab-Islamic medicine); Averroës (Ibn Rushd; 1126–1198); and Moses ben Maimon (Maimonides; 1135–1204), who ended up in Cairo as court physician to Saladin (1138–1193). Razi's work On Measles and Smallpox was still useful enough to be published in English by the Sydenham Society in 1848. Spread over a vast empire, Arab-Islamic medicine vastly expanded the healer's pharmacological arsenal with drugs and remedies from Persian and Indian sources, created the first pharmacies, and laid the chemical (alchemical) foundations of modern pharmacy. The vocabulary of European languages was considerably enriched by this activity and by the creation of medical discourse. Medical education was still mostly a private affair, except in the hospital, an important fixture in cities. Roman hospitals had been restricted to soldiers and slaves; Islamic hospitals open to all (a pious hope) were real medical institutions. In 1365 Granada established the first European mental hospital, following the pioneering institutions in other Islamic countries. It looked as if Greek medical glories had been restored and improved.

How it all came to an end is open to debate. Erwin Ackerknecht explained the decline of Arab-Islamic medicine in Gibbonian terms: early Arab tolerance was submerged in Islamic fanaticism. Just add the triumph of the barbarians and one has a crude version of Edward Gibbon's (1737–1794) model of the decline and fall of the Roman Empire. Christians conquered Cordova in 1236; the Mongols sacked Baghdad in 1258; the Ottoman Turks conquered the Levant—Constantinople fell in 1453—and swept into the Balkans and the Mediterranean. Arab civilization declined after the thirteenth century, but the old medical system survived, especially in the Ottoman Empire, until the nineteenth century and continues to survive in a form known as Yunani medicine (Unani tibb, Greek medicine) on the Indian sub-continent. What influence Arab-Islamic medicine had on the rise of the medical profession in medieval Europe is open to speculation, but it is clear that Arab medicine exercised a powerful intellectual influence on the revival of Greek medicine in the early medieval period.

Medieval physic.

This revival of formal medicine in the West began in the southern Italian town of Salerno, a dynamic, multiethnic place under Norman power; the town is a hundred miles south of the great monastery of Monte Cassino, whose library held a collection of medical texts, and which stimulated an interaction with Salerno. The teachers at the medical school in Salerno developed a good curriculum, founded on their translations of the great texts of Greek (from Arabic) and on Arab medicine. Constantine the African (Constantinus Africanus; c. 1020–1087) was instrumental in transmitting a Galenized Hippocrates to the Latin world with its new concepts, couched in a new technical vocabulary, in anatomy and physiology. By the thirteenth century, an enriched Arabic-tinted medical Latin identified medicine as a separate and elite discipline—and a few centuries later provided medical discourse for Molière. The new medical canon, flattered as the Little Art of Medicine (Articella) in the sixteenth century, was based on a group of translated works, especially Constantine's version of the Liber ysagogarum (Medical questions) or introduction of Hunayn ibn Ishaq al ibadi (Johannicius). This work became the basis for the medical teaching of the difficult art of diagnosis and of the gamble of therapy—Constantine's book on drugs, the Antidotarium, expanded the therapeutic repertoire. This introductory book emphasized the therapeutic need to regulate Galen's "six nonnaturals" (food and drink; sleep and waking; environment; evacuation, including sexual; exercise; and mental state) in order to preserve the natural humoral balance in the body, thus avoiding illness, or to restore balance, thus curing an illness. This emphasis on regimen or lifestyle was made famous in the popular Regimen sanitatis salernitanum, a book of verses perhaps concocted by Arnau de Villanova (c. 1235–1312), physician to the high and mighty (popes and kings) and professor at the University of Montpellier. Many popular works adopted this holistic framework in giving advice to the sick and those trying to stay healthy.

With the economic revival of Europe in the period 1200–1350, there appeared an age of construction in hospitals and universities as society invested in the care of the sick and the production of clergy, lawyers, teachers, and doctors. Medical education, when it was organized in places such as Bologna and Montpellier, was a long, tedious affair (about ten years) attempted by few. Padua, degree mill of the age, granted nine medical and surgical degrees in 1450; it had a large faculty of sixteen. Europe probably produced enough physicians to treat elite patients and to discourse with them in the Aristotelian lingo they both had ingested in the faculties. The rest of the population cured themselves or depended on charlatans (not necessarily a pejorative designation) or empirics of varying degrees of ignorance and skill. Neither doctor nor empiric could do much in dealing with smallpox, influenza, insanity, leprosy (a popular diagnosis in the eleventh and twelfth centuries), and the Bubonic plague (1347–1351), which killed off about a quarter of the European population. The wise doctor limited himself to dietetics, according to the Galenic gospel of the "nonnaturals," some drugs, and a bit of minor surgery. With a degree and well-heeled patients, he could become rich. There was not much competition. In 1454 Vienna, with a population of fifty thousand, had eleven M.D.s.

Medieval surgery.

Surgery, often identified as a craft, has sometimes been promoted to the status of an intellectual adventure. It was certainly a dangerous though not necessarily fatal adventure to have surgery in pre-Listerian times. Roman surgery can appear "remarkably modern," meaning comparable to the surgery of the 1970s (Nutton, p. 57). Great surgeons such as John Bradmore (d. 1402), John of Arderne (c. 1307–1370, and Henri de Mondeville (c. 1260–1320) were remarkably successful in carrying out dangerous operations, some on the battlefield, often improving on ancient techniques. It is not surprising that mortality rates were high; what is surprising is the survival of a patient exposed to massive infection. The ancient technique of using wine to irrigate wounds and incisions is probably one part of the explanation. Surgeons liked to write as well as cut. The leading surgeons produced classic texts, thus following in the literary Hippocratic-Galenic tradition. Outside Italy surgery may not have been a respectable part of the curriculum, but from the twelfth century on, leading surgeons were closer to physicians than to barber-surgeons and empirics; in some towns cooperation between all groups was more striking than clashes. Even snarling Parisian surgeons and physicians could come to a limited agreement in 1210 over dissections. While the doctor envied the surgeon's skill, the surgeon lusted after the doctor's cultural capital and academic baggage. The social status of surgery was helped by the official role of the surgeon in autopsies for investigations of homicide and in the public dissection of criminals. The growing importance of anatomy (including the dissection of human corpses) in medical education during the fourteenth century also promoted the surgeon. Medicine and surgery had become part of society in an unprecedented way as a result of the new governmental function of practitioners and the related development of institutions.

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