MEDICINE IN SOCIETY Historical essays Edited by ANDREW WEAR Lecturer in the History of Medicine, University College London and Wellcome Institute for the History of Medicine CAMBRIDGE UNIVERSITY PRESS Published by the Press Syndicate of the University of Cambridge The Pitt Building, Trumpington Street, Cambridge CB2 1RP 40 West 20th Street, New York, NY 10011-4211 USA 10 Stamford Road, Oakleigh, Melbourne 3166, Australia © Cambridge University Press 1992 First published 1992 Reprinted 1993,1994,1996,1998 A catalogue record for this book is available from the British Library Library of Congress cataloguing in publication data Medicine in society / edited by Andrew Wear. p. cm. ISBN 0-521-33351-2 (hardback), ISBN 0-521-33639-2 (paperback) 1. Medicine - History. 2. Social medicine - History. I. Wear, A. (Andrew), 1946- [DNLM: 1. History of Medicine. 2. Social Conditions - history. WZ 40 H674] R131.H564 1992 362.1'09 - dc2O DLC 91-10962 CIP ISBN 0521 33351 2 hardback ISBN o 521 33639 2 paperback Transferred to digital printing 2003 Medicine and society in medieval Europe, 300—1300 KATHARINE PARK The hallmarks of medieval medical care were its variety and its intensity. Our own society boasts a relatively small (although growing) range of both medical institutions and publicly recognized medical practitioners, narrowly defined, similarly trained, and socially homogeneous. Medieval society, on the other hand, like many present-day traditional societies, looked to a much broader set of healers and strategies to care for its precarious health.1 In part this situation reflected much higher levels of illness than we are used to - levels that sprang from extensive poverty and unhealthy living conditions as much or more than the limits of medieval therapeutics. In part it reflected the variety of medieval society itself. A millenium separated the Europeans of 1500 from their counterparts in 500, and that millenium encompassed changes arguably far more radical than those of the five centuries that separate us from them. Furthermore, Europe was much more diverse then than now, when advances in transportation and communication and other social shifts have acted to homogenize institutions and to break down cultural and linguistic barriers between nations, between city and countryside, between rich and poor. For these reasons, historians have tended to describe medieval medicine as a dense set of discrete forms of theory and practice tenuously related - if related at all - whose principles frequently contradicted one another and whose practitioners rarely overlapped: physic and surgery, academic medicine and empirical medicine, rational medicine and 1 Cf. Margaret Pelling and Charles Webster, 'Medical Practitioners', in Charles Webster (ed.), Health, Medicine and Mortality in the Sixteenth Century (Cambridge, 1979), p. 235. For a general survey of European medicine in this period, see Nancy G. Siraisi, Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice (Chicago, 1990). 59 KATHARINE PARK magical medicine, men's medicine and women's medicine, religious medicine and secular medicine, medicine of the rich and medicine of the poor. Such a view is at best exaggerated. It is increasingly apparent that medieval medicine, for all its diversity, formed a cultural unity. Academic writers incorporated the occult properties of plants and minerals into their pharmacology. 'Popular' vernacular treatises were almost all translated from the Latin. Physicians cooperated with surgeons and midwives. Men treated women and women, men. Institutions such as hospitals and municipal doctors offered high-quality medical care to the poor of both city and countryside. And few people appealed to saints before consulting their local lay practitioner. We cannot understand this complicated social world without considering it whole, including some kinds of health care — faith healing, for example, nursing, or midwifery - that no longer form part of our own more narrowly defined professional medicine. To do so would yield a picture both incoherent and incomplete. Many of my conclusions are tentative; the social history of medieval medicine is a recent and undeveloped field, sources are sparse, especially for the early period, and the variety and breadth of the topic make generalization difficult. I have adopted both a topical and a chronological approach; beginning with a brief account of the special health conditions that shaped medieval medicine, I go on to characterize the social response to those conditions, which I have divided into two main periods: the early medieval period, from roughly 500 to 1050, and the high and late medieval period, from roughly 1050 to 1500. My aim throughout is to trace the gradual growth in medieval society of a complicated and sophisticated medical order. During the later period, I will argue, medicine began to emerge as an autonomous area of expertise, located in an increasingly well defined and differentiated body of practitioners, and in specialized medical insti- tutions newly evolved to organize their practice and draw upon that expertise. A universe of disease Jacques Le Goff has described the European Middle Ages as ' a universe of hunger'.2 It was also, and for many of the same reasons, a universe of disease. Like hunger, illness was arbitrary and inescapable, tied to the caprices of nature. Like hunger, it was serious, frequent, and preoccupying. Much of medieval writing — private letters as well as 2 Jacques Le Goff, La civilisation de /'Occident medieval (Paris, 1964), p. 290, and in general pp. 290—303; translated as Medieval Civilisation, 400—1500, trans. Julia Barrow (Cambridge, MA, 1989), pp. 229-44. 60 Medicine and society in medieval Europe religious and literary texts - reveals an obsession with illness, and medieval saints, mirrors of contemporary anxieties and aspirations, appear above all as healers of the sick. Medieval men and women considered themselves old at forty-five. Although their possible life span was the same as ours, their average life span seems to have hovered between thirty and thirty-five years, dropping to as low as eighteen or twenty years during the half-century after the advent of plague in 1348; this corresponds to a death rate two to four times our own.3 These are of course aggregate figures. Life expectancy was lower in the city than in the countryside and lower for the poor than for the rich, reflecting crowding, malnutrition and material deprivation. It was lower for females than for males, reflecting the dangers of pregnancy and childbed. At risk above all were children, especially infants, whose fragility dominated and drove these high mortality rates; from 15 to 30 per cent (even higher in some periods and areas) seem to have died before the age of one. The overwhelming cause of this premature mortality was disease. The high death rates indicate rates of illness that were truly staggering. The * burden of sickness', as Paul Slacks calls it — the physical and psychological suffering it caused and the economic and social disruption — was far heavier than the burden of death.4 Various causes contributed to these high rates of illness. The technical inadequacies of medieval medicine were partly responsible; medieval doctors knew nothing of antibiotics, antisepsis, or immunization, and they lacked a clear idea of contagion. Far more important, however, were the living conditions of the time. Like many developing nations, pre-industrial Europe was fundamentally poor and its meager wealth extraordinarily unequally distributed. The great majority of the urban and rural population lived at the level of bare subsistence, lacking adequate housing, clothing, fuel, and especially food and drink.5 Their diet was deficient in both quantity and quality, and many lived in conditions of periodic famine and chronic malnutrition, particularly toward the end of the thirteenth century, when western Europe began 3 Summaries of recent research in J. C. Russell, 'Population in Europe, 500-1500', in Carlo M. Cipolla (ed.), The Fontana Economic History of Europe, 6 vols. in 9 (London, 1972-76), 1: The Middle Ages, esp. pp. 41-50, and Carlo M. Cipolla, Before the Industrial Revolution: European Society and Economy 1000—1700, ch. 5; see also associated bibliographies. On old age, David Herlihy, 'Vieillir a Florence au Quattrocento', Annales: Economies, societes, civilisations, 24 (1969), 1338—9. 4 Paul Slack, The Impact of Plague in Tudor and Stuart England (London, 1985), p. 176. 5 Cipolla, Before the Industrial Revolution, chs. 1-3; Maria Serena Mazzi, Salute e societa nel Medioevo (Florence, 1978), pp. 5-26. See in general Thomas McKeown, The Role of Medicine: Dream, Mirage or Nemesis (Princeton, NJ, 1979), esp. chs. 2, 8. 6l KATHARINE PARK to suffer from relative overpopulation.6 The low level of collective and personal hygiene also contributed to disease, particularly in the cities, where sewer systems were inadequate and water supplies often polluted by animal and human waste. Most houses were poorly heated, poorly ventilated, and extraordinarily crowded. Soap was expensive, when available at all, and domestic and human parasites flourished — not only rats, fleas and lice, but also a whole host of micro-organisms and worms. These conditions fostered an exuberantly varied world of disease. Demographers and historians of medicine have tended to concentrate on the more dramatic and exotic episodes in the history of medieval illness, the successive epidemics of plague, leprosy, and