The Greatest Benefit to Mankind: A Medical History of Humanity

Control of midwifery became more common from the fifteenth century. The Papal Bull of 1484 denouncing witchcraft drew attention to alleged attacks by sorceresses on virility and fertility; in their viciously misogynistic Malleus maleficarum (1486) [Hammer of Witches], the Dominicans Henricus Institoris (Heinrich Kramer, fl. 1470–1501) and Jacob Sprenger (fl. 1468–94) accused midwives of murdering babies in the womb, roasting them at sabbaths or offering them to the Devil. There is little evidence, however, that female healers were charged with witchcraft.

Medieval authors on sex and childbirth (or ‘generation’ as the subject was known) drew on a variety of traditions: Aristotle, Galen, Soranus and the Bible. The standard view was that men and women shared a common physiology, but in perfect and flawed versions. Female generative organs were like those of men, but inverted and inferior – the vagina was an inverted penis which had never fully developed. Thus, the female form was a faulty version of the male, weaker, because menstruation and tearfulness displayed a watery, oozing physicality; female flesh was moister and flabbier, men were more muscular. A woman’s body was deficient in the vital heat which allowed the male to refine into semen the surplus blood which women shed in menstruation; likewise, women produced milk instead of semen. Women were leaky vessels (menstruating, crying, lactating), and menstruation was polluting.

De secretis mulierum [On Women’s Secrets] spelt out the harmful effects of menstruation:

women are so full of venom in their time of menstruation that they poison animals by their glance; they infect children in the cradle; they spot the cleanest mirror; and whenever men have sexual intercourse with them, they are made leprous and sometimes cancerous.

The womb was an unstable organ, making women less balanced than men. Social consequences followed from these physiological teachings. According to the instigator of the Reformation, Martin Luther (1483–1546),

Men have broad and large chests, and small narrow hips, and more understanding than women, who have but small and narrow breasts, and broad hips, to the end they should remain at home, sit still, keep house, and bear and bring up children.

Controversies flared among doctors, philosophers and theologians over the gendering and engendering of the body. The roles of the male and female in fecundation were disputed, as Aristotle’s distinction between superior male ‘form’ and inferior female ‘matter’ (seed and seedbed), clashed with the Galenic theory of the confluence of male and female semen to make a baby. Such niceties could have weighty implications: how, for example, had the Virgin Mary conceived Christ – was it from menstrual blood, or was such blood a waste product? Contrasting explanations could also be given regarding the means and the moment of the soul’s entering the foetus.

In the later Middle Ages, medical and Christian views cross-fertilized at many points as the body assumed heightened significance in the humanistic theology of the times. While some, like the early Church Fathers, still viewed it as the prison of the spirit, new emphasis came to be placed on the soul’s incarnation in the flesh, the doctrine of immanentism. In the consecration of the host in the eucharist, the bread was transubstantiated into Christ’s body, turning miraculously to flesh. There was similar stress on bodily resurrection at the Last Judgment. In Catholic rituals, a saint’s power was associated with relics of the body: a hallowed bone, tooth or toenail protecting against evil; hence the booming relics business.

BODIES

Theological concerns loomed large in readings of the body, yet medicine too was concerned with the implications of the theory of embodiment and the soul. Scholastic medicine subscribed to the Chain of Being or Scale of Nature, with man as the midpoint between angels and brutes, distinguished from the beasts by possession of a rational soul. One consequence of this doctrine was that, considered in a purely physical light, the human body could be described in the same terms as that of a pig or a monkey. Belief in such a continuum of creation explains why the earliest medieval anatomies, conducted at Salerno and Bologna, could be performed on animals: the human soul was unique, so similarities between human and animal cadavers were not theologically worrying.

The first recorded public human dissection was conducted in Bologna around 1315 by Mondino de’ Luzzi (c. 1270–1326). Born into a medical family, Mondino graduated at Bologna, and rose to a chair of medicine there. His fame rests on his Anatomia mundini (c. 1316), which became the standard text on the subject. Built on personal experience of human dissection, the Anatomia was a brief, practical guide, treating the parts of the body in the order in which they would be handled in dissection, beginning with the abdominal cavity, the most perishable part. Relying on Galen and the Arabs, the Anatomia perpetuated old errors derived from animal dissections, such as the five-lobed liver and the three-ventricled heart. Mondino’s achievement derived from his intuition that the developing university-based education of his day required an introductory anatomy manual. The first printed version appeared in 1478, followed by at least forty editions – a clear recognition of how central anatomy was becoming to medical expertise.

Hitherto anatomy had played little part in medical education; it had no place in the Articella or the medical school of Salerno, though pigs had been dissected there. But from Mondino’s time learned physicians began to enunciate the view that medicine should be anatomy-based. Thereafter academic physicians gloried in public displays of human dissection and anatomy theatres were built. Dissection was justified largely in terms of natural philosophy and piety (the body demonstrated the wisdom of the Creator); the surgical benefits were rarely mentioned – clear evidence of the professional function of physicians’ anatomical knowledge.

Various factors contributed to the rise of human anatomy, among them Galen’s prestige (after all Galen had prided himself upon his dissecting abilities). Tampering with human remains was far from unknown in medieval Christendom. The wish to bring dead crusaders back from the Holy Land for burial had led to the custom of boiling up bodies to leave only the bones, and to the preservation of the heart of the deceased. Though this practice was condemned by Boniface VIII in 1300, the papal ban proved ineffective. From around 1250, autopsies also became regular in Italian, French and German towns, with surgeons called in to investigate homicide and establish cause of death. The step from a coroner’s postmortem to dissection was small.

Public dissection was spectacle, instruction and edification all in one. The corpse would be that of an executed criminal, presupposing municipal cooperation. It was sometimes staged in a church, usually in winter, since cold slowed putrefaction. Mondino’s order of dissection of the three main bodily cavities – first the lower abdomen, then the thorax and the skull – was designed with decay in mind. In illustrations of dissections, a physician resplendent in academic robes sits on a throne, intoning from a Galenic anatomical text, while a surgeon slits the cadaver with his knife, and a teaching assistant points out notable features. Whether or not dissections were actually conducted in this way, what is conveyed is the ritual of the performance: religious, civic, and university authorities agreed that the occasion must be accorded due gravity.

Book-driven anatomy – a demonstration of what was already known, within the explanatory framework of learned medicine – served many purposes, providing guidance to the student, who would not have been able to see much for himself. From Bologna, human dissection spread; the next key centre was Padua, which was popular with foreign students. In Spain, the first public dissection took place at Lerida in 1391; Vienna held its first in 1404. In England and Germany anatomy teaching with a human corpse did not become routine before 1550.

Anatomy had an impact upon medical illustrations – a subject bedevilled by modern prejudices about ‘realism’, for medievals who drew ‘childish’ images of the bones and arteries have been adversely contrasted with the new ‘scientific’ artists of the Renaissance (notably Leonardo da Vinci), admired for their realistic anatomical drawings. But the comparison is misleading. For one thing, Leonardo at times followed tradition rather than his eye, adopting, for instance, the standard five-lobed liver. For another, it is wrong to think that the apparent crudity of medieval images reveals ineptitude. Late medieval illustrations were not meant to depict minute documentary detail; they were diagrammatic teaching aids, schematically representing general truths – mnemonic rather than photographic.

The most common type of medieval medical illustration was the ‘Zodiac man’: a male figure marked up with blood-letting points or with the zodiac signs (Taurus controlled and cured diseases of the neck and throat, Scorpio the genitals, Capricorn the knees, Pisces the feet, and so forth). The right way and place to let blood was gauged by study of the constellations and the moon. There was also the group known as the ‘five-picture series’, standing for the five systems: arteries, veins, bones, nerves and muscles. Squatting figures with legs astride were occasionally used to show diseases, wounds and the influence of the stars and planets on body parts. There were also charts explaining how to examine urine. The success of such images is evident: they survived into the age of print, wound-men in particular continuing to crop up in surgery texts.

The late Middle Ages wear a gloom-laden appearance: painters gave Death a mocking grin and portrayed him accosting peasants, merchants and princes. Perhaps for this reason, and because it was roundly disparaged by Renaissance humanists, medieval medicine has never enjoyed a good press. Proud of recovering Hippocrates and Galen in the original Greek, humanists chid and despised their muddle-headed predecessors.

We should not blindly accept these judgments. Much was afoot before 1500: in particular the fifteenth century brought a rise in practical medicine, associated with the books of practica and case-histories (consilia) produced by Italian professors. Bedside consultations, autopsies and the spread of dissection gave Italian medical training an increasingly hands-on emphasis. It is ironic that from the 1490s the medical humanists reverted to theory, to philology and medicine’s ‘sacred’ books, notably through the Galen revival.

The later Middle Ages also consolidated the role of medicine in European society, with new institutions and regulations. At the time when the Salerno school was founded, physicians were to be found only in monasteries and palaces; five hundred years later they had infiltrated society (remember the physician on Chaucer’s pilgrimage) and were facing competition from other practitioners like barber-surgeons, professional bickering being but one sign of this growing medical presence. Other domains of life were falling under medical control: health officials directed urban hygiene and combated plague. From birth to death – and even beyond, if one had the misfortune to be cut up for a public anatomy display – medicine gained a hold that it had previously lacked or lost.

* Take for instance this section in the English translation by Sir John Harington (1561–1612) (who was, incidentally, the inventor of the water-closet):

Although you may drink often while you dine,

Yet after dinner touch not once the cup, …

To close your stomach well, this order suits,

Cheese after flesh, Nuts after fish or fruits.

CHAPTER VI INDIAN MEDICINE

EACH AREA OF THE GLOBE has created a medicine of its own. The neolithic revolution in India and China produced civilizations comparable in complexity and achievements to the developments discussed in the Middle East, the Levant and the eastern Mediterranean, like these, founded upon an agrarian economy sustaining, and sustained by, political overlords and large urban settlements. In the great Asiatic empires social hierarchy and the consequent division of labour facilitated the emergence of specialist healers, together with priests, wise men and bureaucrats.

The consolidation of writing encouraged learned traditions which helped to give permanence to particular corpuses of medical (as well as religious and philosophical) erudition. As with the writings of Hippocrates and Galen in the West, the result tended to be a glorification of tradition, and the associated belief that a fixed, permanent and perfect medicine had, in a quasi-divine manner, been handed down from some far-distant origin. It was the duty of successors to uphold such a tradition, protecting and purifying it against the threat of corruption. Such values imparted into Asian medical systems a great durability; they certainly gave no encouragement to innovation. Indian and Chinese medicine alike proved tenacious and encouraged myths of an essential unchangingness – though this was actually belied by developments. The consequence was that both traditional Indian and traditional Chinese medicine continued in place; yet both experienced in due course a tense and ambiguous encounter with western ‘scientific medicine’, which left them compelled to take aspects of it on board.

EARLY INDIA

As in many other parts of the world, the first settled agricultural communities in India appeared at the end of the last Ice Age about ten thousand years ago; around 3000 BC, as archaeology reveals, developments took place around the Indus river leading to elaborate civilization. Excavations of the imposing Indus cities of Harappa, Mohenjo-daro and Lothal have revealed what must have been a complex urban social order, with well-defined social and occupational hierarchies. As well as priests, healers must have existed: perhaps the function was twinned. Remains of great public water tanks in these cities suggest communal bathing and hence cleansing rites, perhaps linking ritual to hygiene.

Around 1500 BC, this Indus civilization seems to have fallen into decay; the explanation for this may lie in climatic and environmental changes affecting the water courses. Meanwhile, the Indo-European peoples were migrating into south Asia, and their civilization achieved a position of dominance in the subcontinent. Brotherhoods of hereditary priests (brahmana) grew powerful, becoming the masters and guardians of Sanskrit religious teachings called veda (the knowledge). Though there is no distinctive ‘Vedic medicine’, such religious writings shed some indirect light on contemporary beliefs about health and healing.

It seems that a magico-religious outlook on illnesses and treatments became established which broadly parallels Mesopotamian or Egyptian practices. Distinctive healing powers were associated with particular deities, it being believed that diseases could be produced by wicked spirits or by happenstance. The deities who brought disease visitations were to be propitiated by rites involving mantra (incantations), supplications and expiation. Herbs were valued for their therapeutic powers, while injuries and broken bones were attributed to everyday causes; but some diseases – conditions like yaksma (perhaps consumption) and takman (fevers associated with the monsoon season) – were judged to be signs of demonic and magical interventions. Beliefs about the body and its workings came from various sources. Vedic rites involved the use of animal and human sacrifice, and the ceremonial texts contain some listings of anatomical parts. Some basic forms of surgery were also recorded, cauterization being employed to stanch wounds, and reeds were used as catheters to relieve the retention of urine. Vedic writings speak of the value of water, whether to be bathed in, drunk or ritually applied.

From perhaps 1000 BC, Veda constituted the main faith of north India. Other groups also were appearing, seemingly dedicated to making religion a more spiritual matter and placing emphasis upon the need to lead a life of moral uprightness. Alongside many individual ascetics, the chief and best known of such groups was the Buddhist community, founded by Gautama Sakyamuni (the Buddha, 563–483 BC). Others included those subsequently called the Jains. These gatherings gave rise to new medical practices.

The monastic rule which governed the lives of Buddhist monks, dedicated to acquiring the ‘peace of mind brought about by the abandonment of desire’, declared that among their meagre belongings should be included five elementary medicines: fresh butter, clarified butter (ghee), oil, honey and molasses. This list expanded in time to embrace a large pharmacopoeia and divers foodstuffs. Archaeological evidence from the fourth century AD shows that some Buddhist monasteries included a sick-room, which may have developed into a more distinct hospital, at around the same time as the emergence of hospitals in the Christian West. Initially, the monks’ healing activities were for fellow brethren, but, as in the West, the monasteries also served the lay community.

In contrast to the earlier Vedic medicine, which is not at all similar to Ayurveda, there are striking resemblances between these Buddhist texts and later Ayurvedic texts on medicinal herbs and on specific treatments. In terms of origins and influences, the Ayurvedic texts are themselves misleading, since they claim a derivation from the Vedic tradition. The reality is that, while the situation is complex and controversial, they probably developed out of the newer ascetic milieu. Best scholarly opinion today holds that the ascetic communities of the fourth century BC onwards, particularly the Buddhist community, played a vital part in the evolution of Ayurveda.

AYURVEDIC MEDICINE

The archetypal system of Indian medicine is called Ayurveda – the knowledge (Sanskrit: veda) needed for longevity (ayus). Ayurvedic teachings amount to a code of life and consist of practical advice concerning all aspects of life, from washing to diet, from exercise to regimen, within a wider Hindu religious philosophy of rebirth, renunciation, and the maintenance of the balance of the soul. Their theoretical foundation lies in the notion of three basic bodily humours (dosas) – wind, bile, and phlegm – which reflect the macrocosmic forces of wind, sun and moon. There are also seven fundamental bodily constituents: chyle, blood, flesh, fat, bone, marrow and semen. The Ayurvedic pharmacopoeia is mainly herbal, prescribing an assortment of therapies including ointments, enemas, douches, massage, sweating and surgery. Though metallic compounds came into medical use from around AD 1000, these remained marginal; opium too was brought in, apparently from Islamic sources, to relieve dysentery. For achieving health, the canonical texts stress temperance in all matters – food, sleep, exercise, sex and medicines themselves. The healthy life is to be consonant with the harmonies of the universe and true religious teachings.

Written in Sanskrit, the earliest surviving Ayurveda texts date from the early centuries of the Christian era; traditional claims among practitioners that Ayurveda dates back thousands of years are pious. Of the various Sanskrit writings that expound the Ayurveda, the earliest are the Caraka Samhita [Caraka’s Compendium] and the Susruta Samhita [Susruta’s Compendium], supposedly the work of the sages Caraka and Susruta. Very substantial in bulk, they form the cornerstone of Ayurveda. A third early text, the Bhela Samhita, survives only in a single damaged manuscript.

The Caraka Samhita tradition is connected with north-western India, and in particular the ancient university of Taksasila; the Susruta Samhita was supposedly composed in Benares on the River Ganges. Their original composition date is a matter of speculation: earlier versions may derive from as far back as the time of the Buddha (early fourth century BC). Caraka may date to around AD 100; Susruta to the fourth century. The Sanskrit texts which became canonical represent the works in the form they had attained around AD 1000.

There are other subsequent prominent Brahminic texts. These include the Astangahrdaya Samhita of Vagbhata (AD C. 600), which includes midwifery, the Rugviniscaya of Madhavakara (AD C. 700), the Sarngadhara Samhita of Sarngadhara (c. fourteenth century AD), and the Bhavaprakasa of Bhavamisra (sixteenth century). Madhavakara’s work broke new ground through rearranging medical topics according to pathological categories, thereby establishing the model of thematic grouping followed by almost all later works. Sarngadhara was the first Sanskrit author to introduce new foreign elements, including opium and metallic compounds, into the materia medica, and the use of pulse lore in diagnosis and prognosis.

The Caraka Samhita and the Susruta Samhita stem from a common intellectual tradition. The Caraka Samhita is marked by long reflective and philosophical passages, including discussions of causality and so forth. The Susruta Samhita for its part contains extensive descriptions of sophisticated surgical techniques: eye operations, plastic surgery, etc., which do not appear in the Caraka Samhita at all or only in less detail. Both are huge compendia of medical teachings on subjects such as a balanced diet; the powers of plants and vegetables; the causes and symptoms of various maladies; epidemic diseases; the right techniques for examining patients; the parts of the body; conception, pregnancy and the way to take care of foetuses; diagnosis and prognosis; stimulants and aphrodisiacs; the nature and treatment of fever, heated blood, swellings, urinary and skin disorders, consumption, insanity, epilepsy, dropsy, piles, asthma, coughs and hiccups and scores of other conditions; cupping, blood-letting, the use of leeches, and many other treatments; the right use of alcohol; the properties of vegetables, nuts, and other materia medica; the use of enemas – and all alongside incantations, omens and fears of sorcery.

The medicines described in the Caraka Samhita and the Susruta Samhita comprise a rich menu of animal, vegetable, and mineral substances. For dealing with the 200 diseases and 150 other conditions mentioned, the Caraka Samhita refers to 177 materials of animal derivation, including snake dung, the milk, flesh, fat, blood, dung, or urine of such animals as the horse, goat, elephant, camel, cow and sheep, the eggs of the sparrow, pea-hen and crocodile, beeswax and honey, and various soups; 341 items of vegetable origin (seeds, flowers, fruit, tree-bark and leaves), and 64 substances of mineral origin (assorted gems, gold, silver, copper, salt, clay, tin, lead and sulphur). The use of dung and urine are standard; since the cow is a holy animal to orthodox Hindus, all its products are purifying. Cow dung was judged to possess disinfectant properties and was prescribed for external use, including fumigation; urine was to be applied externally in many recipes.

The Caraka Samhita praises the virtuous healer: ‘Everyone admires a twice-born [brahmin] physician who is courteous, wise, self-disciplined, and a master of his subject. He is like a guru, a master of life itself.’ Quacks, by contrast, are roundly condemned: ‘As soon as they hear someone is ill, they descend on him and in his hearing speak loudly of their medical expertise.’ In respect of the true physician, the Caraka Samhita tenders an Oath of Initiation, comparable to the Hippocratic Oath. A pupil in Ayurvedic medicine had to vow to be celibate, to speak the truth, to adhere to a vegetarian diet, to be free of envy, and never to carry weapons. He was to obey his master and pledge himself to the relief of his patients, never abandoning or taking sexual advantage of them. He was not to treat enemies of the king or wicked people, and had to desist from treating women unattended by their husbands or guardians. The student had to visit the patient’s home properly chaperoned, and respect the confidentiality of all privileged information pertaining to the patient and his or her household.