The Middle Ages spans a period of over a thousand years from the 5th to the 15th centuries following the collapse of the Roman Empire. The Roman Empire collapsed in 476 AD with the Emperor Augustus being disposed by a Germanic chieftain after being unable to defend its empire against various barbarian onslaughts from the east (1). The Roman Empire, in terms of its infrastructure and public health were world renowned. Rome even had a state medical service and was aware of the very great advantage of providing medical education to ensure a steady supply of physicians for their army and navy. After its collapse, Europe never saw the same level of public healthcare or innovation until the Enlightenment. The very word medieval is often associated with stagnation or even the negation of progress (2). More importantly, with regards to monastic medicine, was the conversion of Constantine the Great to Christianity in 313 AD. Christian Monasticism (rise of Christianity and the role of monasticism).
It is difficult to define medieval social structure given the fact the period lasted over a thousand years and changed very much within that time. To set the social structure in the form of a pyramid, with nobility at the top and peasants at the bottom, as can be done with many other periods in history, would be inaccurate. Within nobility there were varying levels of power and could also be rather fleeting for some families depending on the favour of the king (3). All villages were ruled by a manor house and so all peasants, who made up the majority of the population of Europe, worked off the land that was owned by a noble lord. He exerted a deal of power in his land in matters of law and had the final say in a court of law over such crimes as petty theft and assault. Some peasants were quite prosperous and land could be inherited from generation to generation. Others peasants lived less comfortable lives and relied on the outcome of their harvests year by year. Slavery had not ended with the collapse of the Roman Empire; there was a rare type of slavery known as serfdom. Serfs were was not conceived to be slaves in that the lord of the manor did not own him but he was tied to the land that the lord owned and would have to seek permission if he ever wished to leave it. He owed a certain amount of work to the lord of the manor and was expected to give some proportion of what he made to the lord also. However, this system worked well for a serf in that, a lord could not dispose of a serf without good reason and so was always assured of having land (4). In general terms, society could be divided into those who fought, those who worked and those who prayed.
Those who prayed were figures in the community such as priests or those who lived communally in monasteries. It began very early on in the history of Christianity with Christians going into the desert, particularly in Egypt, renouncing the material world to spend a life in prayer and to serve to God. As Christianity spread through the Roman Empire, many religious persons began to live in communities together but it was usually to live a life of asceticism and to serve God in a particular way such as serving the poor or educating others as opposed to living in community with like-minded Christians. Out of these monasteries, arose particular orders such as that of St Benedict. The Benedictine order began in Italy in the 6th century and spread throughout Europe. It laid particular emphasis on ensuring the recovery of sick monks by going to great lengths to make them comfortable and to answer to their every complaint (5). Benedictine’s rule states, ‘Before all things and above all things, care must be taken of the sick, so that they may be served in very deed as Christ himself’ (6). By the middle ages, there were about a thousand monasteries in England and they were socially and economically active institutions (7). However, the choice of monastic life was not open to all. It was reserved for the wellborn of society who would often enter the monastic life at a young age (8). Especially in the case of female monastics, marriage and dowries were often too costly for even noble families to pay. Instead, families would often endow a monastery so that it would favour their daughters. It would often happen that several of the female’s relatives were currently in the monastery.
In many ways, monastic life was not only a means of striving towards perfection and having a fuller relationship with God but also as a viable career choice with many opportunities. In the environment of a monastery one could learn, teach, translate and print classical texts and belong to a safe, peaceful environment away from the violence and wars of the time.
A considerable contribution that the monastic life brought to medicine in the medieval period was the building of hospitals. Hospitals were religious foundations through and through (9). Almost half of all hospitals were affiliated with a monastery, priory or church (10).Early on in the beginning on monastic life, the responsibility of care of the sick, lay on the religious orders (11). Most monasteries had a hospital for their sick or work worn members. This was rather beneficial in a society that did not have welfare for its sick and infirm adults. During the ninth century, monks began to treat nobility as well as the peasants in their area (12). Separate hospitals for lay people were set up in monasteries and people living in the towns could even be transferred to other monastic infirmaries if it was thought that the physician there would be better suited to treat the patient’s illness (13).
The hospitals were usually adjoined to the monastery in the form of a great hall. These halls were either laid out in an aisle and or open plan. The open plan layout was very similar to the layout of most wards today with the beds at right angles to the walls. Towards the 15th century, these open planned halls were being transformed into cubicles so that each room was private (14). There was also a separate kitchen attached specifically to the infirmary which prepared meat. Healthy monastics were generally not allowed to eat meat but they understood the importance of healthy, nourishing food during illness. The meals for the sick were prepared in these kitchens away from the rest of the monastery. (15) Hospitals became quite sophisticated and in comparison to today’s hospitals, despite their lack of resources, would still be adequate today. Most monasteries had a clean supply of running water from a near by stream. They secured this by the formation of drains made out of stone. The monastics would use separate supplies of water from the same stream to avoid contamination if the water was being used for different purposes (16). There were many additional rooms to the monastic infirmaries such as dispensaries, blood letting rooms and physic gardens (17).
Although it may be said that monastic infirmaries were more concerned with the soul over the body, medieval monastic hospitals did have a healing mission. Cassiodorus (c. 485 – c. 585), a Roman statesman who, in retirement, founded a monastery said, ‘learn, therefore, the properties of herbs and perform the compounding of drugs punctiliously; but do not place your hope in herbs and do not trust health to human counsels. For although the art of medicine be found to be established by the Lord, he who without doubt grants life to men makes them sound.’ (18) Whatever criticisms monastic and medieval medicine receive today with regards to their religious ethos, rituals and associated miracles, their success can be proved by the financial support they received and their increasing numbers throughout the medieval period. Without monastic infirmaries and the charity of the monastics, one has to wonder whether such hospitals would have existed.
Treatment of pathologies in the medieval period had not advanced a great deal since the Roman period. Rome itself, did not have a native medicinal practice, they copied the teachings of the Greeks and provided them with schools and opportunities to teach other citizens. As teaching progressed, however, Hippocrates teachings of observation and nature were over shadowed with some rather elaborate theories with regards to pathologies (19). The works of Galen (AD 129 – 199/217), a Roman doctor, were particularly esteemed by the Church because he taught that the blood was a vehicle for the soul. Any other physician of scientist who tried to debate this issue would be denounced as a heretic. Therefore, Galen’s medicine and theories along with their various inaccuracies and mistakes persisted in to the middle ages unchallenged for the most part. Roman medicine taught that there were four humours in the body (phlegm, black bile, yellow bile and blood) and illness would occur when these were not in balance with one another. In the medieval times, these humours were changed to temperaments (sanguine, phlegmatic, melancholy and choleric) and the theory became more elaborate with pathologies depending on the interactions between the four temperaments, the four seasons and the four elements (heat, cold, moisture and dryness). These interactions would determine treatment (20). These views on humouralism were so long used for the next 1200 years that it was difficult to challenge them. Also, in a society were nearly all of the population worked in agriculture, people must have been aware of their complete dependence on the fertility of the earth and the balance of the seasons and would surely have associated this with their own health (21).
A medieval painting showing the four temperaments
Out with the monasteries in Europe, the first medical school to be set up was in Salerno. Salerno is situated in Italy, south of Naples. This was considered to be the border between the medieval east and medieval west. It was at this medical school that, ‘Latin Christendom gained access to the tradition of Hippocratic learning rationalised by Galen and digested by Arabs’ who were much more advanced in their school of thinking (22). This was primarily due to the fact that the main religion was Islam and the Church had no authority there. This allowed some of the advancing practises of medicine to reach medieval Europe. The Salerno Medical School also had rather modern views in that it allowed women to practise and to teach medicine. However, many physicians at the time who tried to challenge Galen’s views were branded heretics and others spent most of their research trying to find the elixir of life: a medicine that would provide immortality and eternal youth. Some medical findings did come out of this research. Arnold of Villanova (1235–1311) discovered that alcohol could extract the properties of herbs called a tincture (23). Various other medical schools were founded in European cities and some surprising medical practices can be found such as the father and son surgeons Hugh and Theodoric of Lucca (1214) using mandrake root and opium as a form of anaesthetic (24).
One has to wonder within the confines of a monastery if there was ay contribution made to medicine by monastics and, rather surprisingly, there are some notable figures. Every monastery had a physic garden where plants used in the treatments of patients would be grown. Herbs such as, ‘peony, ginger, cinnamon and balsam were expected to be always available to the comfort of the sick’ and money was spent on other luxury goods such as, ‘aniseed, wine, cassis, cloves, saxifrage, liquorice, olive oil, vinegar and scammy.’ (25)This was compensated by contributions made by people who were keen to secure their admission to a monastic infirmary in old age. It was like an early form of health insurance.
By the 11th century, monastic physicians were being trained to a high level and were often sought by all the nobility in the treatment of their ailments. Papal decree did not allow monastics to charge for their services. Most monastics entered a monastery in childhood and would be trained up to the job as dispensary (26). It can be easily understood that the quiet, intense environment of a monastery would be the perfect setting for one to develop an extensive knowledge of medicine. There were many prognostic measures that monastic physicians took. Monastics often looked at urine, blood and bodily features to diagnose a patient. It was not particularly sophisticated however, and was mostly used to determine whether a patient would live or die (27). This was quite a crucial aspect of monastic care firstly because knowing what patients were going to die absolved a monastic from any blame and secondly, because it allowed the monastics to focus on patients that they could help. It was also of great importance for monastics to prepare a funeral and pray for the patient’s soul if they knew that the patient was going to die. As well as tending to the sick, the arrangement of funerals was another key role of the dispensary (28). The death of a patient was the only occasion when a monk or nun was allowed to run to the dead patient’s body and pray for its soul.
On the Properties of Things (by Bartholomew the Englishman), depicts a physician examining a urinal at a patient's bedside.
One figure in medieval medical history that has created a great deal of interest in modern times is Hildegard of Bingen in Germany (1098-1179). As the tenth child, she was offered to a joint monastery for monks and nuns. She wrote a book called, ‘Causae et curae’ which displays her thoughts on medical teaching. Her theory was based heavily on the four temperaments and she closely linked gardening and nature to the function of the human body (29). Just as one may plant a seed of a particular breed, each patient had a particular balance of the temperaments within them and so had to be treated according to their own balance of temperaments (30). This notion of individually treating patients in a holistic manner may seem like a relatively new concept with regards to disease such as cancer. It was quite a modern view even if the theory of treatment itself was flawed. Her book discussed many topics, such as diagnosis and treatments and it even covered psychiatric disorders. The book itself is written as a manual. With regards to practices such a blood letting and making herbal compounds, little instruction is given on how to practically conduct these procedures. This suggests that this book was a supplement to her teachings to other nuns and that she, herself, already had considerable medical knowledge (31). Hildegard of Bingen is quite a significant monastic from history. Not only did she write of medicine but also of philosophy and was the composer of some of the first Gregorian chants. As a monastic, she had a unique voice in society were the only other viable, respected roles for a women were wife and mother. In her sixties, she toured Europe giving talks to a mostly male audience. She was a respected member of philosophical debates of the time (32). Unfortunately, many contemporary accounts of her practice have been exaggerated by those around her and almost all were ascribed by others as miracles. Other monastic figures include the Dominican monk Albertus Magnus (1192-1280) who is said to have had an encyclopaedic knowledge of philosophy, theology and natural sciences. He wrote a book called, ‘De Vegetabilis et Plantis’ (On Vegetables and Plants). It remained an authoritative text for many years and it contained many original botanical observations (33).
Hildegard of Bingen (1098-1179) recording her visions from God
A very noteworthy contribution that monastics made to medicine was their copying and translating of classical medical texts. Printing was a laborious and costly process and parchment was expensive and all copying was completed by hand (34). Every monastery had a library containing the translations of many medical books (35). They were the preservers of the classical texts. The physicians would also make small changes to the texts with regards to observations that they themselves had made. Although the facts were old and unchallenged, it is still an invaluable source for historians today; to look back and understand the theories of classical and medieval medicine.
Medieval medicine is often thought to have stagnated after the Roman Empire and there were no real developments up until the Enlightenment. As far as Europe and medical developments are concerned, over the thousand year period, new and clinically accurate medicine was not a frequent occurrence. However, it is understandably difficult to challenge the theory of the four temperaments when they had been a common belief for several hundred years. Monastics, through their practice of medicine and care of the sick, have made a significant contribution. Without their charitable care of the sick, it is difficult to consider what the elderly, sick and infirm of medieval society would have done. Without their intense training, it is doubted whether most villages would have had access to a skilled physician. They may not have practiced accurate medicine in today’s terms or believed that treatment of the body took priority over the soul but they did care for the welfare of patients. They cared about education and knowledge, they were custodians of classical texts and they provided care for noblemen, townsfolk alike.
Porter, R. The Greatest Benefit to Mankind: A Medical History of Humanity from Anitquity to the Present. London: Harper Collins; 1997.