Part 1 of The Catholic Church and Healing by James J Walsh

The greatest contribution at once to medical science and to the health and happiness of mankind in the field of medicine was the elaboration of the doctrine of infection and of that of disease prevention by prophylactic measures. Churchmen beginning in the days of the Fathers of the Church took up the problem of the eradication of leprosy following the injunctions laid down in Leviticus, and as a result there came the recognition of contagion and the possibility of its prevention. This was an absolutely new idea in the history of medicine.

It seems very strange to us that the wise old Greeks usually so acute in observation did not discover the principle of infection and contagion, but they did not. Sudhoff, the German historian of medicine, so dependable in such generalizations, said in his Essays in the History of Medicine: (1). The fundamental idea of infection and a definite grasp of the prophylactic measures implicit in it, failed entirely to take root in classical antiquity. He adds that it was not until the fifth century of the Christian era that in the course of medical tradition we first encounter an explicit statement of the transmission of disease by contact (contact infection) and its restriction by isolation. He goes so far as to say quite emphatically that:

"It was reserved for the actual Middle Ages to elaborate serious official measures against the spread of epidemics which were consciously and even dutifully derived from the leper ritual of the Jews with its fundamental concept of isolation. Long before this in the east the Book of Leviticus had already engendered a school of thought in this matter quite apart from Judaism. This came to fruition particularly among the Fathers of the Christian Church. In his ever memorable hospital city of Cesarea, Basil the Great materialized the centric idea of charitable sick nursing in the loftiest manner, and even provided for and erected an isolation house or home for lepers".

The eradication of leprosy, which has been treated in the preceding chapter demonstrates how thoroughly and successfully the Middle Ages applied the idea of disease prevention by definite regulation and restriction of contact.

The entire system of legal restriction and quarantine, as we know it now, was brought forth in connection with these ideas as a result of the effort to overcome the epidemics of bubonic plague which ravaged Europe so mercilessly in the latter half of the fourteenth century. Even priests were placed under the obligation to notify the authorities as to every case of plague that became known to them in administering Extreme Unction to the dying. The most meticulous precautions were taken against the spread of disease. Letters brought in by pose were fumigated. Gold money was disinfected, the bedding of plague patients was burned, domestic animals were placed under control because there was more than a suspicion aroused that they could under certain circumstances be the carriers of disease. Finally the cities were kept clean through the control of streets and water supplies.

This had all developed out of the state of mind which had come into existence in connection with the system of warding off the contagion of leprosy. As the result of this, people came to see allied conditions due to infection in a more intelligent and clear-eyed way and they were more ready to submit to regulations, and physicians were ever so much more convinced of the good that might be accomplished this way. In connection with this, as Sudhoff says, In the thirteenth century so forward in science and knowledge the general concept of contagious diseases became current.

The definite organization of what we would call a crusade of information among the people for the prevention of disease took place and a set of mnemonic verses was elaborated so that people might carry the necessary information about with them easily and communicate it to others in a form under which it was likely to be remembered. In a time when reading was not common and printing had not yet been invented and when the writing out of such verses required a good deal of labor, the composition of them in a readily memorizable form solved the problem of the popular diffusion of information with regard to contagion and the prophylaxis of disease.

By the beginning of the fourteenth century, no less than thirteen infectious diseases, from which people were to protect themselves and the carriers of which were to be avoided, found a place in these mnemonic verses. These diseases as enumerated by Sudhoff were plague, the exanthematous fevers, that is the febrile conditions associated with eruptions of the skin, typhoid, typhus and scarlet fever, measles and the like, phthisis, anthrax, trachoma and gonorrheal conjunctivitis, scabies and erysipelas and manifestly a series of rather serious infections which passed under the name of that disease or were called the fire of St. Anthony or other names suggested by the redness and fever and throbbing which accompany them.

The crusade of popular information, moreover, was complemented by the development and legal institution of practical sanitary regulation. Municipal authorities were required to put patients suffering from these diseases outside the city gates and keep them there for a definite time. Thirty days were supposed to be enough at first but after a while forty days were required and as the ecclesiastical term for this period was a quarantine, this word was adopted into sanitary use and now we speak of quarantine not as a length of time but as segregation from others. This would seem to indicate how close the ecclesiastical authorities were to the development of quarantine practices and of the prophylaxis of disease generally. Above all, the civil authorities forbade those suffering from disease or who were intimately in contact with patients from having anything to do with traffic and articles of food and drink as well as other materials of intimate human association with the person that might be expected to carry the disease. (2)

Sudhoff has emphasized particularly that this organization of prophylaxis against contagious disease, which had remained hidden from the Greeks, occurred during the Middle Ages which are so often spoken of contemptuously as regards their science or medicine. He said, "all this is the achievement of the 'gloomy Middle Ages' hitherto penalized as the period of medical scholasticism though now with tardy justice recognized as having accomplished good work". He adds that, "in the matter of recognition of contagion and prophylaxis by isolation, the most rigorous line was taken at the instance of physicians by the city authorities of northern Italy and southern France". At this time the popes were in residence at Avignon in southern France and many of the distinguished physicians of the time were among the papal physicians. The doctrine of contagion and the possibility of prevention continued to exist in Italy to a much more definite degree than in other countries. Both in Italy and in Spain there were laws that recognized the contagiousness of tuberculosis, insisted on quarantine for the disease and required the destruction of everything with which patients had been in contact.

Dr. Flick, in his Development of our Knowledge of Tuberculosis (3), says that as the result of the recognition of the contagiousness of disease there is a tradition that the Indians in that part of America colonized by the Spaniards remained free from tuberculosis for a much longer period than those who were in that part of the country colonized by England and France. He suggests that, so far as this was true, it no doubt was due to interference with emigration of tuberculosis people to America by the laws of Spain. Unfortunately after a time the doctrine of the non-contagiousness of consumption gained a foothold and the result was a great increase in the disease until in our own time more definite precautions with regard to its possible spread were taken. The Renaissance and its intense preoccupation with Greek medicine undid not a little of the good work in the prevention of disease which the Middle Ages had accomplished. The feeling of scholars was that if the Greeks did not have it then it was not worth while paying any attention to it.

Toward the end of the first half of the sixteenth century Fracastorius, the distinguished Italian physician of Verona, redeemed the Renaissance period in this regard by restating the theory of contagion. The popularization of Fracastorius ideas, especially among the clergy, came as the result of Father Athanasius Kircher s book on the pest or bubonic plague which was written in Rome in the generation that witnessed Galileo s trial. Father Kircher thought that he had seen little animalcules or living things that produce disease. He had observed cases of plague in a nunnery where they had been very careful to prevent all communication with the outside world. He attributed the spread of the disease inside the walls of the nunnery to the visits of a cat and thus revived the idea of intermediate carriers of disease which had been the subject of so much solicitude during the Middle Ages. The medieval achievement in the recognition of infection and the practice of disease prevention is one of the great triumphs in medicine.

(1) New York, 1926

(2) It was only after the New York legislature In the second half of the nineteenth century was brought to the realization that clothing was being manufactured in slum quarters of New York City, where sometimes smallpox and typhoid fever and even Asiatic cholera were rife, and that this clothing might be carried out of the city and so transport the disease to other portions of the state, that we were able to secure, a little more than a generation ago, the enactment of the sanitary code and the establishment of the Department of Health which has done so much to bring about improvement in New York s health and reduce the death rate. It is surprising to find that the medieval cities, six centuries before New York, succeeded in accomplishing the same purpose.

(3) Philadelphia, 1925.

CHAPTER V

MONASTIC MEDICINE, THE TRADITION

OF ANESTHESIA, MEDICAL TEACHING

With the fall of the Roman Empire and the further invasion of the Roman world by the barbarians, culture and civilization to a very great extent disappeared and only what the monasteries preserved of the intellectual life remained. The monks were more interested in religion than in medicine, but the copyists in the monasteries saved many of the medical classics from disappearing. Besides, the charity of Christ urged them to the care of the ailing, and this led them to the preservation of precious medical traditions. The monasteries were houses of call for travelers and as a result inevitably had to assume the care of ailing travelers who contracted or developed disease on their journey.

Besides, most of the monasteries had tenant farmers on their estates and the monks were interested in their health. Finally there was the infirmary in the monasteries for the ailing monks as well as in the convents for sick nuns; and infirmarians were provided with expert knowledge, as far as possible, to care for the ailing. These infirmarians gathered whatever medical knowledge they could obtain, making use of the monastic medical traditions to the best advantage.

The Rule of Benedict, founder of the monks of the West, said: Before all things and above all things care must be taken of the sick. Benedict himself died of fever contracted while caring for the poor near Monte Cassino. An example of this kind on the part of their founder could not fail to be fruitful. The Benedictine monasteries became the repository of important traditions in medicine and surgery, and their scriptoriums or writing rooms preserved many of the old Greek medical writings from perishing from the face of the earth in the midst of the contemporary neglect of the intellectual life during the invasion of the barbarians in the early Middle Ages. (1). Their gardens supplied the herbs which were considered to be so precious for the treatment of the various human ills even down to our own day. The beginnings of modern medical education can be traced mainly to monastic influence.

The relationship between medicine and the monasteries in the early days is well illustrated also in the career of Cassiodorus. Early in life he attracted the attention of King Theodoric, of whom he became prime minister. After the death of the king, Cassiodorus at the age of fifty felt that he could do more good by his example in the religious life.

A few years previously Benedict had founded the religious order, afterwards to be called the Benedictines, at Monte Cassino, and it was undoubtedly in imitation of Benedict s institution that Cassiodorus erected the monastery of Vivarium on his own estate. Here he lived to the ripe old age of ninety-three, spending almost as much of his life as a monk as he had spent in the world. Cassiodorus himself drew up the rule of is monastery, and he emphasized the fact that monks should make researches and devote themselves to the increase of knowledge. He called attention particularly to the needs of the monastery in the matter of a knowledge of medicine on the part of its infirmarians, and he equipped the monastery library with a number of the best-known medical books of the Greeks. There is a definite tradition that he made it an obligation upon the infirmarians who had charge of the sick in the monasteries to consult the works of Hippocrates and Galen and to be guided by them in their care of the ailing. Herbal or Galenical medicine as it is called, after Galen the great Greek physician of Marcus Aurelius at Rome, owes the preservation of the traditions of therapy and the supply of the ingredients for the practice of it to the monasteries. (2).

Shakespeare s picture of the monk in medicine is not a poetic fancy but a portrayal of the realities of history. Friar Lawrence in Romeo and Juliet represents a survival of the tradition that monastery gardens were the usual source of plants and simples of various kinds that would be beneficial for ailing mankind. Friar Lawrence himself in the play suggests that he knew not only the qualities of plants but also of minerals. He was a true Galenist:

Oh micle is the powerful grace that lies

In herbs, plants, Stones and their true qualities:

For naught so vile but on the earth doth live,

But to the earth some special good doth give.

It is the friar who proposes to Juliet the brave and wise strategem of taking the potion which shall set her to sleep for a definite period until Romeo may come and take her from the tomb and bear her away with him to await a time when it may be possible for them to bring about a reconciliation between their two families. The fact that this tradition of anesthesia or narcosis continued to be passed on from generation to generation in the monasteries is now well recognized.

This tradition of the use of anesthesia for surgical purposes has now been traced back to Alexandria when the great medical school there made its magnificent contributions to medicine and surgery. The first definite mention of anesthesia in modem history is in the writings of St. Hilary of Poitiers. The passage was written about 356. For those who think of anesthesia as a modern discovery it is astounding to read the straight- forward account, as Hilary presents it, of how men could be brought under the influence of an anesthetic and have various rather serious operations, even the amputation of limbs, performed on them without suffering any pain. Here are Hilary s own words. They occur in the midst of a discussion of the psychology of sensation. (3).

When the body is pricked or pierced, it is the soul which pervades it that is conscious and suffers pain. For instance a flesh wound is felt even to the bone while the fingers feel nothing when we cut the nails which protrude from the flesh. And if through some disease a limb becomes withered, it loses the feeling of the living flesh: it can be cut or burned, it feels no pain whatever, because the soul is no longer mingled with it. Also when through some grave necessity part of the body must be cut away, the soul can be lulled to sleep by drugs, which overcome the pain, and produce in the mind a death-like forgetfulness of its power of sense. Then the limb can be cut off without pain. The flesh is dead to all feelings, and does not heed the deep thrust of the knife because the soul within is asleep.

Sudhoff, the German historian of medicine, has collected the references to the use of the spongia somnifera, sleep-bringing sponge, in his Archives of the History of Medicine. (4). They are all monastic in association. There is a very definite reference to it in the Antido tarium Nicolii which comes from Salerno. For a time it was thought that the idea originated there. Later a reference to the spongia was found in the Bamberger Antidotarium.

This dates from the ninth century. Then a reference of the same kind was found in the Cassineser Rezeptar, that is the prescription book or collection of recipes for medical purposes in use at Monte Cassino, the great motherhouse of the Benedictines. Manifestly the sleep sponge had been known in the earlier half of the Middle Ages. The practice of anesthesia for surgical purposes seems to have been part of the tradition of the Irish monks.

Dr. More Madden called attention to the fact that a Celtic materia medico, that is a work which describes the various drug materials used in medicine and surgery in the twelfth century, contains a reference to a compound containing mandrake and other materials to be used before cuttings and punctures in order that there might not be pain with them. It said further, By means of this it is possible for anyone to secure sleep by just smelling it. In the note to the chapter Ancient Irish Medicine in my volume, The World s Debt to the Irish, (5), there is this paragraph:

In proof of the antiquity of the use of anaesthetics in the Irish monastic tradition. Dr. More Madden quoted a passage from Jocelyn s life of Kentigern or St. Mungo, patron of Glasgow, a book written sometime between 1185 and 1199. This life which is edited from the unique manuscript in the British Museum (Cott. vat. c. viii) of the twelfth century, was written by the celebrated Jocelyn of Furness, the biographer of St. Patrick, and is dedicated to another Jocelyn, bishop of Glasgow. That passage runs,

It is perfectly clear to us that many having taken the drink of oblivion which physicians called the lethargion, have as a result gone to sleep; incisions in their members and at times cauterizations even in their most vital pares or abrasions have occurred without their feeling them in the least. After they were awaked from their sleep they were entirely ignorant of the fact that anything had been done to them.

In the original medieval Latin the passage runs:

Constat nibilominus nobis multos, sumptu potu oblivionis quem physici letbargion vacant obdormire; et in membris incisionem, et aliquotiens adustionem et in vitalibuo, abrasionem perpessos, minime sensisse, et post somni excussionem, quae erga sese actiata fuerant ignorasse.

Arthur Oehm, in the Hemmeter Festschrift number of Medical Life (6) says that:

In the sixth century monasteries were notably founded by Irish and Scotch monks who had been better able to maintain and preserve the heritage of Greece in the arts and sciences than the continental institutions, being removed from the destructive turmoil of the continent . . . .

We know from statements of Columban, from the correspondence of Boniface and especially from the works of the Venerable Bede that the monks of Ireland and England did not neglect matters pertaining to medicine and made use of this knowledge at the bedside . . . they gradually transplanted medical ideas (largely derived from their classical learning) all over the territory that they traversed. Some of these monks came to have a great reputation for their skill in medicine.

A very interesting illustration of the Church s care for those in need and of the very intelligent efforts that were made to help them, anticipating measures that were supposed to be developed ever so much later in the world s history, is the account which the Venerable Bede gives of the teaching of the deaf by St. John of Beverly. Up to this time it had usually been considered that people thus afflicted had but very slight intelligence. John of Beverly who had had a varied career, after his retirement from the archbishopric of York devoted himself to the teaching of these unfortunates. As a younger man he was a member of the community under St. Hilda at Whitby.

Afterwards he was bishop of Hexham and then Archbishop of York. After resigning this see to his pupil, Wilfrid, John established a monastery at Inderawood, afterwards called Beverly, which became an extremely important educational center. It was in connection with this that his special efforts were extended to the deaf mutes.

One of these deaf mutes proved to have unusual intelligence so John devoted himself to enabling the young man to develop his mental ability. Venerable Bede, who was himself a pupil of John, tells that the saint taught his deaf and dumb pupil to read the lips and to speak. The great English church historian was very much inclined to think that his success must be considered almost miraculous and that it was the merits of St. John which brought to the young man the blessing of speech.

People who read the story in Venerable Bede, before the day when we actually had the experience that the deaf could not only be taught to read the lips but also to articulate for themselves, would surely have dismissed it as representing one of those curious tendencies to believe the impossible which was so characteristic of the Middle Ages, or else they would have set it own as one of the miracles that friends came to relate of saints in order to bring them into honor.

John of Beverly was a Benedictine and his work probably continued for some time among his brethren and then was lost sight of. He died sometime toward the end of the first quarter of the eighth century and we have no further record of attempts to teach the deaf and dumb until the sixteenth century in Spain when a Father Pedro Ponce de Leon (7) also a Benedictine, taught many deaf pupils. It had become the custom to think once more that these poor afflicted ones were dummies not only physically but mentally, but Father de Leon whose charity was inexhaustible found that all that was needed was time and patient teaching to bring out their intelligence. (8).

The beginning of medical education in modern history came with the foundation of the medical school at Salerno, a city in southern Italy some thirty miles away from Naples. There is some question as to how far the Benedictine school at Salerno was an important factor in the establishment of the medical school there. The Benedictine school, a foundation from Monte Cassino not far away, can be traced back to the ninth century. There is no doubt that a rather close relationship existed between this school and the professors of medicine. The greatest figure in the medical school at Salerno was Constantine Africanus who brought back with him from his travels in the orient an immense amount of information with regard to medicine. He had collected also a large number of manuscripts.

Constantine became the intimate friend of Abbot Desiderius of Monte Cassino. This friendship developed while Desiderius as a simple monk was teaching in the Benedictine school of Salerno. When Desiderius was elected the abbot of Monte Cassino, Constantine became a monk at Monte Cassino and continued his great work of providing foundation stones for modern medicine. The medical school at Salerno became the great medium for the diffusion of the medical writings which Constantine in the peace of Monte Cassino was engaged so sedulously in giving to the world of his time.

Professor Sudhoff declares that the influence which Constantine Africanus exerted at Salerno was profound. His personal relations to the Salernitan school were transient but his medical publications were of great importance. Those most certainly written by him found a willing and almost eager reception and application in practice. He became the exponent of an extensive new endogenous literature. Constantine s works represented the beginning of modern medicine.

Much of what he wrote was adopted and adapted from the Arabic medical writers; but there was no little jealousy between Christians and Arabs, and the result had been a neglect of Arabic medicine which because of the intimate contact of the Arabs in Asia Minor with the old Greek medical sources was very valuable. When published by Constantine under his own name and with the prestige afforded by his brotherhood in the order of the Benedictines of Monte Cassino, these works attracted attention and meant very much for the beginning of the development of European medicine.

After Constantine one of the greatest figures at Salerno was Alphanus, usually designated the first because there are several of that name. He was a Benedictine monk, known by his contemporaries as both poet and physician, who was afterwards raised to the bishopric of Salerno. This succession of events illustrates very clearly how intimate the relations of the Benedictines and the pioneer medical school at Salerno continued to be for centuries, for Alphanus lived in the twelfth century.

As the latter half of the Middle Ages began, there is evidence for the important place of the Benedictines in medicine because of the works of an abbess of a Benedictine nunnery which have attracted much attention in recent years. She is now proclaimed to have been the most important writer on scientific and medical subjects in the twelfth century. She is known in history as St. Hildegarde, and was the abbess of Disibodenberg not far from Bingen on the Rhine.

Some most surprising hints of medical knowledge are to be found in her works. She seems to have had some inkling of the circulation of the blood and, surprisingly enough, she wrote about problems of heredity and certain sex subjects that might have been expected to be outside of her sphere of attention.

When we recall, however, that in the preceding century a Benedictine nun Hroswitha of Gandersheim wrote the first comedies of modern time with the declaration that they were written to supersede the reading of Terence, objectionable because of sex elements in his plays, it is easy to understand Hildegarde s writing on these subjects. Some of the expressions of modern commentators with regard to Hildegarde s writing reveal their appreciation of her work. Melanie Lepinska in her Paris thesis on Hildegarde just at the beginning of the twentieth century, suggests that:

Hildegarde foretold auto-infections and seemed almost to foretell or to comprehend the circulation of the blood, she recognized the brain as the regulator of all the vital processes and as the centre of life, understood the influence of the nervous system and the spinal cord on the process of development. ... In short a profound intellect reflecting on all subjects with the intuition of genius full of experience, embracing the whole science of her time: so does she appear in her first medical work.

Hildegarde is of interest particularly because she represents the culmination of the traditions of medical lore and of hospital care for the ailing in the Benedictine nunneries. Much is due to her own genius but undoubtedly, also, much is due to her knowledge of what had gone before and to the accumulation of information which the nuns had secured in their work down the centuries since their foundation. A recent tribute to St. Hildegarde is the article on The Scientific Views and Visions of St. Hildegarde, by Dr. Charles Singer, which is the leading article in the volume. Studies in the History and Method of Science (9). This is really a monograph on the subject for it contains nearly sixty pages of a quarto volume. Dr. Singer thus speaks of her work:

Hildegarde was a woman of extraordinarily active and independent mind. She was not only gifted with a thoroughly efficient intellect but was possessed of great energy and considerable literary power and her writings cover a wide range betraying the most varied activities and remarkable imaginative faculties.

What she knew about science is contained in two volumes bearing the names Liber simplicis medicinae and Liber compositae medicinae. Most of what Hildegarde wrote comes to us in a single copy, of none is there more than four copies, showing how near we came to missing all knowledge of her entirely.

Undoubtedly there were many other writings, and some of them on medical subjects, by these nuns as well as the monks of the Middle Ages, but these disappeared with the vicissitudes of time. The reformation, so-called, worked sad havoc with monastic libraries. Some of them contained the most precious materials for the understanding of medieval life and knowledge. They were destroyed partly through neglect but mainly through contempt for medieval scholars and their work.

END NOTES

(1). Sometimes there is a distinct surprise to find what these old monastic scriveners had preserved. One can scarcely help but have the feeling that they must have rather thoroughly appreciated the value of some ideas that are usually supposed to have been quite beyond their ken. The frontispiece or the recently issued Hippocrates with an English Translation by Dr. E. Withington (Oxford University Press, 1927) is a reproduction of the Apollonius illustration of the shouldering method of reducing the shoulder joint. In this illustration the patient is represented as taken on another s shoulders, and by manipulation in this position the dislocated shoulder is replaced. Dr. Withington says of it: It is doubtless a fairly accurate copy of the one thousand years older original by Apollonius himself or the artist he employed. The surprise is to find how well the medieval scrivener or artist of the eleventh century appreciated the value of the illustration for the understanding of the method and therefore reproduced it.

(2). It has sometimes been suggested that the monastery gardens would be scarcely large enough for the supply of all the simples that were needed or at least were used, but then monastery gardens can be employed for purposes like this with very great economy. We must not forget that almost in our time Mendel did his great work and succeeded in working out his important laws of heredity in a monastery garden that was scarcely as large as a small-sized city lot.

(3) De Trinitate, Book X, ch. 14, quoted in Schnaff-Wace, Nicene and Post-Nicene Fathers, Vol. IX, p. 185, chap. 2.

(4) Archiv fur Geschichte der Medizin, B. XIII, Heft. 3, 4, 1921.

(5) Boston, 1926.

(6) New York, April, 1927

(7) 1520-1584.

(8) This subject is discussed more fully in my volume, Spain's Golden Century, N. Y., 1928.

(9) Clarendon Press, Oxford, 1917.

CHAPTER VI

THE CARE OF THE INSANE

There has been more misunderstanding, in the modern time, of the relations of the Church to healing because of ignorance of the stand taken by medieval ecclesiastics toward insanity and the insane, than for any other reasons. It is usually said that until modern times insanity was thought to be due to possession by an evil spirit, and therefore the only way to treat the insane was by exorcising these spirits. It is presumed by many that the position taken by the Church in this important matter discouraged physicians from studying mental disease and led to an utter failure of anything like proper care for these poor patients who were, as we understand so well now, sufferers from disease just as much as those who had bodily ills of various kinds.

The idea, however, that there was a very general acceptance of the notion that insanity was practically always caused by possession by evil spirits is entirely without substantiation in what we have come to know of the history of the Middle Ages. That idea is very largely due to the presumption with regard to spirit possession that grew up during the witchcraft delusion. It must not be forgotten, however, that the witchcraft delusion is not medieval but modern in its date and was at its height during the seventeenth century.

There is only one way that the attitude of the Church and churchmen toward the insane in the Middle Ages can be determined and that is through the formal teaching of theologians and those who wrote books touching the subject that were approved by the ecclesiastical authorities of the time. These furnish a very different impression from anything like the belief in insanity as due to the possession of evil spirits. We have one very striking testimony in this matter and that comes from the compendium of information compiled by Bartholomew the Englishman (Bartholomaeus Anglicus) for the use of priests.

There are a great many practical questions on which priests ought to be well informed, and these Bartholomew, who was a learned Franciscan friar, gathered into a single volume of encyclopedic character so that answers might be readily available for anyone seeking information. His book was very much read and continued to be used as a manual of information for some four centuries. It exists in a large number of manuscript copies which would indicate that Bartholomew was one of the most widely read of the serious authors of the Middle Ages.

Even before the invention of printing the book had been translated into half a dozen modern languages. It was originally written in Latin but the French translation made by an Augustinian, Jean Corbichon, is itself a literary monument in French and there are further translations into Italian, Spanish, English and Provencal.

After printing came in, Bartholomew s book, the title of which is De proprietatibus rerum, The Properties of Things, was published in a number of editions, no less than three times as an incunabulum that is before 1501 and more than a dozen times afterwards. There was evidently great call for the book. It was meant particularly for priests, and was evidently used by all the clerics that is, by practically all those who could read at that time.

What Bartholomew has to say with regard to insanity represents the opinion of the churchmen of his time better than could be obtained from any other source. His work was actually used as a textbook in the schools of theology and may be quoted confidently as constituting the source of knowledge on all these dubious questions. Bartholomew condensed what he had to say with regard to the causes, the symptoms and treatment of insanity into a single brief paragraph.

Bartholomew knows all the causes of insanity and mentions them. They are passion, overwork, overthought, sorrow, too deep study and fear. These are the mental causes. But he knows also that there are physical factors that bring about disturbance of mentality. Insanity may come as the result of an infection, from the bite of a mad dog or some other venomous animal. Bartholomew was aware, moreover, that insanity may come from overeating as well as from the overdrinking of strong wine.

He warns that not all the patients suffer in the same way, and he describes the two principal forms of mania or excitement and melancholia or depression. These two continued to be the center of attention until the end of the nineteenth century.

Bartholomew warns of the possibility of the insane hurting themselves or others. For this reason they must be restrained. As for their treatment, there must be such change of environment as will renew their health and strength and they must be withdrawn from business and from the source of their dreads and whatever else may be disturbing. Finally music must be provided for their entertainment and occupation secured for them. A change of environment, entertainment, occupation, these are the very latest developments in our care of the insane. Here is Bartholomew s paragraph from the translation by Berthelet made nearly four hundred years ago but with the spelling modified so as to make it easier to understand at the present time.

Madness cometh sometime of passions of the soul, as of business and of great thoughts, of sorrow and of too great study, and of dread: sometime of the biting of a wood (mad) hound, or some other venomous beast; sometime of melancholy meats, and sometime of drink of strong wine. And as the causes be diverse, the tokens and signs be diverse. For some cry and leap and hurt and wound themselves and other men, and darken and hide themselves in privy and secret places. The medicine of them is, that they be bound, that they hurt not themselves and other men. And namely, such shall be refreshed, and comforted, and withdrawn from cause and matter of dread and busy thoughts. And they must be gladded with instruments of music, and some deal be occupied.

This paragraph of instruction for priests with regard to insanity is one of the best brief formulas on the subject that we have. I doubt whether any one could do better at the present time than was actually accomplished by this medieval friar who wrote sometime about 1240. His influence, more than that of any other, continued to be felt on the subject until long after the Reformation. Unfortunately the development of the witchcraft delusion and the decadence of hospitals after the Reformation brought about the serious neglect of the insane and popularized the idea of possession by evil spirits.

The Catholic countries were ever so much less affected by the witchcraft delusion than the reformed countries, and the deterioration of hospitals was not nearly so marked in them. In Italy and in Spain the hospitals for the care of the insane continued to be maintained under much better conditions than those in the countries which had been disturbed by Luther s movement. The medieval monasteries undoubtedly were often an asylum for the feeble-minded and for the milder insane, as well as for the simple-minded who get along very well if they are only allowed to work quietly and peacefully, and if people do not try to impose on them. The children of the nobility who were not quite right in mind were cared for by the monks, but the monastery afforded provision for the others for charity s sake and gave them an opportunity to work and be occupied and thus secure the only happiness possible for them.

We have come to realize in our time that the farm system of caring for such people is best for them in every way, especially if they can be given the opportunity to do regular work under conditions that are not too hard. Even at the present time there are a good many monasteries and nunneries where there are two or three or more simple-minded persons who found it extremely difficult to get along with ordinary employers and yet find it easy to get along with the Sisters, and who work faithfully for years and are about as happy as people can be. There were no institutions for these people in the older times, and the monasteries supplied the place of them and accomplished what we are only just beginning to do again by means of our colony and village systems of caring for the milder insane.

Special care for the insane was provided at first in the general hospitals in connection with other ailing people. This may seem an unfavorable condition, but manifestly special arrangements were made for them; and what alienists desire at the present time is that special wards should be set aside in the general hospitals for the care of the insane, so that they may be under observation early in their cases. As it is, even at the present time, the stigma supposed to attach to insanity, for which there is no good reason, often keeps people from sending patients to the asylum until there are already outspoken symptoms of insanity. If sent earlier many of these cases might be saved from the further development of their affection and placed in conditions under which improvement rather than deterioration would take place.

After a time special hospitals or asylums for the insane were organized. Bethlehem hospital in London in the thirteenth century, after having been a general hospital, came to be used exclusively for the insane. As a result the word Bethlehem, in the speech of the Londoners softened into Bedlam, came to have the special significance of anything related to insanity. The insane people were known as Bedlamers or Bedlamites and still later as Bedlam beggars, though attached to this expression there is a very interesting social and medical development that must be touched upon because it tells the story of one phase of arrangements for the care of the insane. In the later Middle Ages the insane were not yet rigorously confined; but if they had shown any improvement and their delusions were over and they had become capable to some extent at least of caring for themselves, they were allowed to leave the hospital for a time.

There was a condition, however, that they should wear a badge indicating that they had been for a time under surveillance at Bedlam. It might seem to modern ideas to be a hardship thus to expose them to public recognition but it worked to their advantage. All those who came in contact with them took pity on the poor fellows who had been in the asylum and gave them charity, but above all were careful not to irritate them nor to impose on them. In other words, the Bedlamers were committed to the care of the general public at the time when feeling for the fellow man ran high and they fared very well.

This fact was noted by the sturdy vagrants (validi vagrantes) of all kinds who tried to secure one of these Bedlam badges because possession of it gave them a chance for an easy life. Such abuses of charity are very well known and never more so than in our own time. On the death of possessors of Bedlam badges others who had no right to wear them proceeded to make use of them. Occasionally they stole them from rightful owners. The state of affairs which developed can be understood best from Shakespeare s presentation of a counterfeit Bedlamer, in the person of Gloucester s legitimate son, in King Lear.

In all this story of care for the insane in the Middle Ages there was no question of possession by the evil spirits nor was there in the first phase of development of care for the insane which occurred in the little town of Gheel in Belgium.

St. Dympna, an Irish girl, who had come over with the missionaries from Ireland and who in her lifetime had been very much interested in the insane and feeble-minded children, was martyred in Belgium. After her death feeble-minded children and mild young insane patients were brought to her shrine in the hope of relief or cure through her intercession.

The friends of the patients did not expect immediate cure so they left them to be cared for in the families of the villagers near the shrine. This practice has continued for more than a thousand years and has been eminently successful. Mrs. Vernon Kellogg, the wife of the United States Food Commissioner in Belgium during the war, described (1) her personal experiences in Gheel and brought out the fact that very probably this is the ideal system for caring for such patients.

What we find, then, in the history of care for the insane under Christianity is very different from the common impression with regard to it. First there is the colony system or village method of caring for the insane which developed at Gheel and is now looked upon as probably the best way to care for these patients. Secondly there is the open-door system of caring for the insane with provision for committing the insane when they are out of the asylum to the special care of the public. The place that the idea of spirit possession takes as the cause of insanity or exorcism in its treatment is of very minor importance. Bartholomew s succinct paragraph shows how thoroughly insanity was understood.

The great abuses in the care of the insane which had to be corrected during the nineteenth century and some of which are in existence at the present time developed in connection with the deterioration of hospitals after the Reformation. Both Spain and Italy maintained much better institutions for the care of the insane than the other countries of Europe. The use of chains and manacles for the control of the insane is not a medieval but a modern abuse. When the reform of insane asylums was taken up seriously, the Sisters institutions were particularly valuable in introducing high standards of gentleness and sympathy in the care for these poor unfortunates. The most serious conditions prevailed in the State institutions and particularly in the county poorhouses in various parts of the world where the insane and the paupers were under the same roof. Even yet many of these institutions are a disgrace to modern civilization.

(1) Atlantic Monthly, 1926.

CHAPTER VII

THE CHURCH AND SURGERY

One of the greatest surprises in the development of documentary history in our generation was the discovery that there had been a magnificent evolution of surgery during the twelfth and thirteenth centuries in Italy, beginning with the great medical school at Salerno but spreading all over the Italian peninsula and making its way into France and England. For this chapter in history we are not dependent on vague traditions but fortunately are in possession of the actual textbooks of the professors who taught surgery in the Italian and French universities of the time. The preservation of them before printing through the laborious process of hand copying is a tribute to the thoroughgoing appreciation of the generations that copied them so faithfully, and fortunately most of them were printed among the incunabula (before 1501) and made safe from the vicissitudes of time.

These textbooks are a revelation. It was astounding to find that surgeons at the end of the Middle Ages, supposed to be so lacking in this department, had actually been doing much better surgery than the surgeons of the nineteenth century ventured upon until a decade or two, at least, after Lister came to revolutionize modern surgery.

This was all the more surprising because a special historical tradition had been created in the English-speaking countries that the practice of surgery was forbidden by the Church in order to encourage the use of prayer and Masses and relics and the visitation of shrines from which the Church would derive more revenue. Professor Andrew D. White, in his work, The Warfare of Science with Theology, declared that, invoking as a guiding principle, ecclesia abhorret a sanguine ( the Church abhors the shedding of blood) ecclesiastics prevented the development of surgery. He adds:

So deeply was the idea rooted in the mind of the universal Church that for over a thousand years surgery was considered dishonorable. The greatest monarchs were often unable to secure an ordinary surgical operation and it was only in 1406 that a better beginning was made when the Emperor Wentzel of Germany ordered that dishonor should no longer attach to the surgical profession.

The situation thus conjured up enables him to emphasize ecclesiastical hypocrisy by the suggestion that the Church was not chary of shedding blood in other ways.

As a matter of fact during the two centuries and a half immediately preceding this date given by President White there was a marvelous development of surgery. The outstanding surprise of medical history has been the discovery and revelation of this fact in the past generation. Pagel, the well-known German historian of medicine says:

A more favorable star shone during the whole Middle Ages over surgery than over practical medicine . . . . The stream of works on surgery flows surgery has a huge volume concerned almost entirely with surgeons who did their work during the very richly during this period.

Gurlt in his great history of surgery has a hugh volume concerned almost entirely with surgeons who did their work during the very centuries when President White says there was no surgery. The historian of The Warfare of Science with Theology had evidently never looked into the history of surgery.

The beginning of the great development of surgerywas at Salerno in the last quarter of the twelfth century. The first important textbook was written by Roger and then came his pupil Rolando who wrote a commentary on his master s work. This combined textbook was subsequently annotated by a group of South Italian surgeons known as the Four Masters. Gurlt himself, one of our most distinguished surgeons at the end of the nineteenth century who went back to the originals, declared that this textbook shows clearly that writers drew their opinions from a rich experience. They were intent on observation rather than theory, and their textbook is a treasure house of valuable hints for the surgeons not only of their day but of all generations since.

These surgeons from Salerno, for instance, knew the possibility of fracture of the skull by contrecoup. They say, Quite frequently though the blow comes on the anterior part of the cranium fracture occurs on the opposite side. They tell the story of a boy wounded in the head by a thrown stone apparently without serious result though he died the next day. When his cranium was opened a large amount of black blood was found coagulated beneath his dura mater.

Since then many a boy has died, after being hit on the head by a missile, because his surgeon did not realize the possibility of rupture of the middle meningeal artery.

Professor Clifford Allbutt, Regius Professor of Medicine at Cambridge (England), in his Historical Relations of Medicine and Surgery Down to the Sixteenth Century, (1) says of their method of caring for wounds:

They washed the wound with wine scrupulously removing every foreign particle; then they brought the edges together, not allowing wine nor anything else to remain within dry adhesive surfaces were their desire. Nature, they said, produces the means of union in a viscous exudation or natural balm. ... In older wounds they did their best to obtain union by cleansing, desiccation and refreshing of the edges.

The experience of surgeons during the Great War brought them round to many of these old-fashioned ideas once more. Theodoric comes nearest to us of all these old surgeons. He wrote in 1266:

For it is not necessary as Roger and Roland (of Salerno) have written, as many of their disciples teach and as all modern surgeons profess, that pus should be generated in wounds. No error can be greater than this. Such a practice is indeed to hinder nature, prolong the disease and to prevent the conglutination and consolidation of the wounds.

And yet for five hundred years after his time laudable pus was the best that surgery could hope to secure after surgical intervention. Theodoric himself was a bishop and wrote his textbook on surgery mainly in order to preserve the teaching of his father, the famous Ugo of Lucca. He was very proud of the work that his father had done and he boasted of the linear cicatrices hich he used to secure without the use of any ointment.

He impugned the use of poultices with oil on the wounds and declared that powders were too drying and besides they had a tendency to cake and thus prevent drainage. The literal meaning of the words which Theodoric uses saniem incarcerare is to incarcerate sanious material. One is not surprised after that to find that Theodoric has many hints as to the practical treatment of surgical affections that are anticipations of developments of our time.

Theodoric was followed by William of Salicet who imitated Theodoric in getting away from the Arabic abuse of the cautery and brought the knife back again to its proper place as the ideal surgical instrument.

Gurlt, in his history of surgery, devotes more than ten pages of rather fine print to William and his work, insisting that William depended much more upon his own experience than upon what was to be found in textbooks. He knew what had been written before his time, very well, but as a rule he did not quote from his predecessors unless he had tried the recommendations for himself or unless similar cases had come under his own observation.

The next of these great Italian surgeons masquerades under a French name because he was professor of surgery at Paris. This is Lanfranc whose family name however was Lanfranchi or Lanfranco and who is sometimes spoken of as Alanfrancus. He practiced as a physician and surgeon in Milan until banished from there by the Visconti about 1290. He removed to Lyons where he attracted so much attention that he was offered a professorship of surgery in Paris. Gurlt says he attracted almost an incredible number of scholars to Paris and by hundreds they accompanied him to the bedside of his patients and witnessed his operations.

Lanfranc completed his surgery called Chirurgia Magna in 1296 and dedicated it to Philippe Le Bel, the reigning French king. He thus described the character that a surgeon should possess:

A surgeon should have a temperate disposition well under control ... he should have well formed hands, long slender fingers, a strong body not inclined to tremble and with all his members trained to the capable fulfilment of the wishes of his mind. He should be of a deep intelligence and of a simple, modest, brave but not audacious disposition. He should be well grounded in natural science and should know not only medicine but every part of philosophy; he should know logic well so as to be able to understand what is written and should talk well so as to support what he has to say by good reasons.

Lanfranc clearly had a high ideal for his profession. He had some very practical hints for young surgeons. For instance:

The surgeon should not love difficult cases and should not allow himself to be tempted to undertake those that are desperate. He should help the poor as far as he can but he should not hesitate to ask for good fees from the rich.

The next of the great surgeons of this period was the successor of Lanfranc at Paris, Henri de Mondeville. Old writers usually quote him as Henricus. The first edition of his book ever printed we owe to Professor Pagel who published it at Berlin in 1892. Gurit in his History has given over forty pages, much of it being small type, with regard to Mondeville because of the special interest there is in his writing. This would represent a volume of good size because Gurlt s pages are large. He was a great teacher of surgery. Here is his idea of the training of a surgeon:

A surgeon who wishes to operate regularly ought first for a long time to frequent places in which skilled surgeons operate frequently and he ought to pay careful attention to their operations and commit their technique to memory. Then he ought to associate himself with them in doing operations. A man cannot be a good surgeon unless he knows both the art and science of medicine and especially anatomy. The characteristics of a good surgeon are that he should be moderately bold, not given to disputation before those who do not know medicine, operate with foresight and wisdom, not beginning dangerous operations until he has provided himself with everything necessary for lessening the danger . . . . He must be highly moral, should care for the poor for God s sake, see that he is well paid by the rich, should comfort his patients by pleasant discourse and should always accede to their requests if these do not interfere with the cure of the disease.

He had been a student of Lanfranc as may be seen by these expressions, but he went much farther than his master and was evidently a great-souled member of his profession. He emphasized very much the need of keeping the patient s mind in favorable condition.

Let the surgeon take care to regulate the whole regimen of the patient s life for joy and happiness, by promising that he will soon be well, by allowing his relatives and special friends to cheer him and by having some one to tell him Jokes.

Let him be solaced also by music on the viol or psaltery. The surgeon must forbid anger, hatred and sadness in the patient and remind him that the body grows fat from joy and thin from sadness.

Mondeville has much to say with regard to the assistants who share with the surgeon his care of the patients. He feels that they often put obstacles and difficulties in the way of convalescents. He insists then that:

The surgeon must be careful in the selection of nurses and attendants for some of them obey very well while he is present but do as they like and often just exactly the opposite of what he has directed when he is away.

Just what the status of these attendants of whom Mondeville talks was at that time, we are not sure. There would seem to have been both men and women trained for the special purpose of caring for patients. Some of these were undoubtedly medical students, others were young physicians, but still others must have been what we would call nurses or orderlies.

There is scarcely a feature of modern surgery that Mondeville does not touch on in his writings. The picture of the surgeon of France at the end of the fourteenth century, as he gives it, affords a very interesting demonstration of how thoroughly surgery developed in the later Middle Ages. This rather detailed account is all the more interesting when confronted with the impression that prevailed in many minds that the Church had so hampered the evolution of surgery that even monarchs found it difficult to have operations done on them. These surgeons of the thirteenth and fourteenth century were actually doing very much better surgery, as can be readily seen from their textbooks, than was being done anywhere in the world between 1800 and 1850.

Mondeville s personal attitude toward the Church is very well illustrated by his dedication of his textbook of surgery. He says in the preface, that he:

Began to write it for the honor and praise of Christ Jesus and the Virgin Mary, of the saints and martyrs, Cosmas and Damien, and of King Philip of France as well as his four children and on the proposal and request of Master William of Brescia, distinguished professor in the science of medicine and formerly physician to Popes Boniface IV and Clement, the present pope.

There is good reason to think that most of these medieval surgeons who reached distinction were in Holy Orders.

We know that Theodoric was a bishop and that William of Salicer was in minor orders, as probably also Lanfranc. Guy de Chauliac, the father of French surgery as he has been called, was the canon of a cathedral; and while this does not necessarily imply that he was in major orders, he was surely a cleric. Mondeville was very much disturbed, however, by the presumption of some priests in assuming direction of patients and giving them medical advice. He said that some of the clergy of his time seemed to think that a knowledge of medicine was infused into them with the sacrament of Holy Orders. He deprecated that idea very much. (2).

Chauliac, the next of these great surgeons, was born in the south of France, but like all those who reached distinction at this time he was educated in Italy. He describes the many dissections that were made in Bologna where his master Bertruccio taught anatomy by dissection. This is the period when President White says there were no dissections because the Church was opposed to them. The great French surgeon s attitude toward anatomical knowledge by actual study of the cadaver can be judged from his well-known expression that:

The surgeon, ignorant of anatomy, carves the human body like a blind man carving wood.

After his Bologna experience Chauliac went to Paris where Lanfranc was developing the Italian surgical tradition on French soil and attracting an incredible number of students to Paris. Lanfranc s successor was Mondeville, who was followed by Guy de Chauliac; and these three lifted French surgery up to a plane which according to Pagel, the German historian of medicine, enabled Frenchmen to maintain their position as the leading surgeons of the world until the nineteenth century.

Chauliac had a series of experiences at other places and then settled down in Lyons and achieved a great reputation. It was while here that he was summoned to become papal physician and he served in this capacity for three popes. Clement VI, Innocent VI and Urban V. It was in the leisure afforded him by this position that he wrote his Chirurgia Magna which, as he tells us, was undertaken as solatium senectutis, a solace for his old age.

Many other surgeons in succeeding centuries reached distinction in the universities founded under decrees of the popes. The careers of a number of them may be read in my volume on Medieval Medicine (3) With the decadence of hospitals surgery sank to an almost incredible degree until only minor surgery and surgical operations in the face of impending death continued to be done. Nothing is more surprising than this deterioration of surgery and yet it is easily explained. For good surgery three conditions are necessary good hospitals, good nursing, good surgery. The Reformation brought decadence to the hospitals, suppressed the nurses, and the surgeons lost their skill under the impossible conditions that resulted. Modern surgery dates from Lister and the reform of hospitals fifty years ago.

END NOTES