When the Plague struck the West in the middle years of the fourteenth century, no one really knew how to prevent or treat the disease. Many thought they did, but no diet or bloodletting or prayers or concoctions proved successful. The culture's intellectual framework for dealing with illness was deeply flawed, and therefore the various guesses people made based upon it were flawed. From 1348 to 1500 many physicians, Muslim and Christian, wrote treatises on the Plague, and scores of these survive. They contain clear evidence of this flawed framework and the largely useless advice that emerged from it. The failure of medieval medicine stems from stubborn adherence to ancient authorities and reluctance to change the model of human physiology and disease that they presented. The discoveries and inventions that did finally effect this change, however, took place over hundreds of years. Around 1700, a century after development of the microscope and telescope, scholars and physicians were still offering astrological explanations for the Plague and ignoring the tiny animals the human eye could now detect. A century after that they were still blaming the noxious "exhalations" of earthquakes for poisoning the air and causing the Plague. The accurate model of bubonic plague and its successful treatment are only a century old, while the Black Death began 550 years ago.
the medieval physician
The fourteenth-century physician found himself ill prepared in theory and practice to confront the Black Death. Medical theory and practice relied heavily upon the imperfectly understood ideas of the fourth-
century b.c.e. Greek physician Hippocrates and philosopher Aristotle and the second-century Greco-Roman physician Galen (see biography). Each of these men in turn had moved human understanding of illness beyond the mythological "the gods did it" to a rationally structured, if often incorrect, series of purely physical explanations. The ninth-century Muslim medical scholar Hunayn bin Ishaq al-Ibadi and his colleagues in Baghdad translated into Arabic the important works of these men and their Byzantine commentators. Later generations of Muslim physicians and writers such as the tenth-century Persians Abu Bakr ar-Razi and Avicenna and twelfth-century Avenzoar and Averroes of Cordoba, Spain, built upon these foundations by further study and, most importantly, the experience of treating patients. They also tied the theory and practice of astrology much more closely to practical medicine than had been done before. Modern medicine ascribes great influence to one's genes, and similarly medieval physicians ascribed great influence to the celestial bodies: sun, moon, planets, and stars. Muslim doctors rationalized the impacts of these bodies on the four fluids—or humors—that the Greeks had declared were inside the human body: blood, phlegm, and black and yellow bile. A proper balance among these fluids—humoral balance—was vital for good health, and the heavens played their role in maintaining or disrupting this. But the Greeks had taught that other factors, such as diet, environment, and even mood also played their roles, and the Muslims worked with these ideas as well, not least because they could be modified far more easily than the stars or a person's horoscope. Islamic medicine, then, was an amalgam of Greek misinformation and rationalism, Near Eastern astrology, and personal experience interpreted through these filters.
The Christian West had its first medical school at Salerno in southern Italy. As it developed in the eleventh and twelfth centuries, it received the evolving Muslim medical doctrine in the form of translations by the monk Constantine the African and by Jewish scholars at Toledo, Spain. In 1180, Count William VII of Montpellier chartered the medical school at Montpellier, France; Paris and Avignon received theirs in 1253 and 1303, respectively. In the Catholic university, education was heavily philosophical and only mildly practical. The Christian religion had little to say about the nature of the human body, so the absorption of Muslim and pagan Greek medical science—with all of its flaws—presented few problems. Western medicine thus began with the interrelationships of the four elements that constitute all natural things, including the body (earth, air, fire, and water), the four qualities that define them (hot, cold, moist, and dry), the four humors, and the planetary and zodiacal influences on the earth and on individuals. Since astronomy, which was indistinguishable from astrology in many ways, was a standard subject in the basic university arts curriculum, medical students had easy access to experts on the stars. University of Bologna medical students were formally students of physica & astrologica, and from 1405 underwent a full curriculum of mathematics and astrology. This was also true of central and eastern European universities, as at Erfurt, Vienna, Krakow, and Leipzig; at Paris medicine and astrology were divorced as late as 1537.1
As for anatomy and physiology, physicians still labored under much of the nonsense found in the fourth-century b.c.e. Greek philosopher Plato's Timaeus, verbal descriptions drawn from the Roman Galen's work, and simplistic and misleading schematics in medical textbooks. As students they witnessed only the occasional dissection, if any. Here Church authorities were responsible for preventing or limiting the routine practice of autopsy, which seemed to violate prohibitions against willfully destroying a human body—even a dead one. The earliest public dissection in the Latin West apparently took place in Bologna in 1281, but students had to wait thirty years for their first female corpse. In 1316 the earliest known dissecting manual appeared, the Anathomia by Mon-dino de'Luzzi, but it could not have sold well, since the only medical school to add regular dissections before the Black Death was at the University of Padua in northern Italy.2 Many Muslims, on the other hand, believed with Averroes that "whosoever becomes fully familiar with human anatomy and physiology, his faith in God will increase."3 At the time of the Black Death the Spanish-Arab Abi Gafar Ahmed ibn Khatimah defined medicine itself as "an art which through research and experiment has arisen with the object of maintaining the natural temperament, and of restoring it to him who has lost it."4 Despite this advanced approach, however, Muslim doctors were no better able to treat the Plague successfully than Christian. Medieval medical ignorance and impotence cannot simply be laid at the Catholic Church's door, as some scholars do.
Of Christian European regions Italy tended to be best served by physicians, who were available both in cities and the countryside.5 At the time of the Plague France had around 1,700 doctors, about 100 of whom resided in Paris. Roughly half of these were connected to the university there. This was about three times the number found in the previous century.6 But many of the French physicians directly served noble families and not the general public, while Italian doctors in cities were organized in guilds, partaking heartily of civic life and treating all. English physicians, whose training often included study at Padua or Paris, were more like their French cousins, and organized for only a brief time in the 1420s.7 Guilds policed the performance of their members and judged disputes that stemmed from claims of malpractice. Where physicians were guildsmen, as in Italy, this contributed to the solidarity of the profession and the uniformity of practice. In most countries people distinguished between medical men who had had university training and barber-surgeons, who were educated through apprenticeship and carried out most medical procedures, from bonesetting to minor surgery. Both utilized the services of pharmacists, or apothecaries, who prepared and provided various herbs, minerals, pills, and concoctions as the doctor ordered. Though not university trained, pharmacists were respected and powerful professionals on whom physicians relied for their own success. In most places people had access to folk-healers and midwives and other nonprofessional health care providers. In many ways the physicians were least competent among all these, due to the very education that gave them high status.
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