Collapse of the Roman Empire
- The Roman Empire split into an Eastern Empire and a Western Empire in AD 395. In AD 410 the Goths invaded Italy and Roman troops were withdrawn from provinces, including Britain.
- The last Roman Emperor in the West was deposed by a German chieftain in AD 476. This led to a very rapid collapse of social organisation, technical skills and academic knowledge.
- In AD 431 Nestorius, the Christian Patriarch of Jerusalem, was banished for heresy and travelled further East to Persia. There he set up a centre of medical learning that translated the works of Hippocrates and Galen into Arabic.
- The knowledge of the Greek and Roman eras migrated east and was lost, but not irretrievably, from the western end of the Mediterranean and Europe.
- The fall of the Roman Empire really did have a devastating effect on medicine. This was one of the biggest turning points in the history of medicine.
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Barbarians and Superstition
- In England the partly Romanised and partly Christian Celts were gradually overwhelmed by waves of pagan Saxons coming across the North Sea. The Saxons brought with them a return to medical cures based mostly on superstition and magic. So complete was the loss of knowledge that many Saxons believed that the ruins of Roman architecture they saw around them were the work of giants and other mythical beings.
- Not only did the public health systems of the Romans fall into disrepair, but the people of the Dark Ages lacked the education to understand the value of hygiene, clean water etc. Many of the Roman towns were abandoned in favour of small dispersed farmsteads.
- The Christian Church re-established itself in Britain from both the east and the west - St. Augustine arrived in Kent in AD 597 and Celtic monks came from Ireland. The Synod of Whitby (AD 663) brought about the dominance of the Roman version of Christianity. This brought Britain into the Church, which provided some of the communication and unity with the rest of Europe that had once been seen in the western Roman Empire.
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- Aristotle's four humours, Galen's treatment by opposites and Hippocrates' clinical observation lived on with the Arabists (the name given to those following Arabic schools of medicine).
- In the ninth century, Hunain ibn Ishaq (also known by his Latin name Johannitius) travelled from Baghdad, the then capital of the Islamic empire, to Byzantium to collect medical texts. He translated these into Arabic.
- In about AD 910 al-Razi (or Rhazes) distinguished smallpox and measles as separate diseases
- Avicenna, a Persian (AD 980-1037) wrote the 'Canon of Medicine' which brought together the ideas of Aristotle, Galen and Hippocrates. This book was the most important means by which the classical ideas got back into Western Europe.
- In the 12th century Avenzoar (or Ibn Zuhr) describd the parasite that causes scabies and began to question the reliability of Galen - as did Ibn al-Nafis in the 13th century, who suggested (correctly) that the blood flowed from one side of the heart to the other via the lungs - and did not cross the septum. Ibn al-Nafis' work was unknown in the West until the 20th century.
- Despite Islamic prohibition on human dissection some progress in surgery was made and Albucasis (or Abu al-Qasim, born AD 936) wrote a well thought out book describing amputations, the removal of bladder stones and dental surgery - as well as methods for handling fractures and dislocations and the sewing of wounds.
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Arab Social Organisation
- The Islamic empire maintained medical schools. Exams for doctors were held in Baghdad from AD 931.
- Major cities such as Baghdad, Cairo, Damascus and Cordoba had piped water, public baths and hospitals before AD 1000.
- They didn't just translate texts - they made some progress, even though they hindered like many Greeks and Romans by religious objections to human dissection.
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- Alchemy was the attempt to turn base (ordinary) metals into gold and to discover the elixir of eternal life.
- Alchemy traces its origins back to the Egyptians and like much else of ancient and classical learning, it was preserved by the Arabic empire.
- Unlike modern chemistry, much superstition was included - an unsuccessful experiment was as likely to be blamed on the position of the stars or the spiritual purity of the alchemist as anything else.
- Even so, Arabic alchemists invented useful techniques such as distillation and sublimation, and prepared useful drugs such as laundanum , benzoin and camphor.
- The search for an elixir of life says a lot about medical knowledge of the time, and many useful techniques and drugs were developed
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- Avicenna's interest in the Greek philosophers produced enemies such as al-Ghazali who wrote 'destruction of the Philosophers' and encouraged a decline in rationalist philosophy in the Islamic world.
- Avicenna did not believe in personal immortality or that God was interested in individuals. He did not believe the world creation story either. This goes against the orthodox Islamic tradition. Even so, Avicenna was one of Islam's most influential philosophers.
- The rise to power of the Mamelukes (slave-soldiers) in 1250 brought a new hardness to the Islamic world. This was partly in response to the excesses of the Christian crusades.
- The Crusades were a series of wars fought by Christian Europeans against the Muslims. They were an ultimately unsuccessful attempt to retake Jerusalem and the surounding areas associated with the early history of Christianity.
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- Scholarship in the early Middle Ages in Europe was dominated by the Catholic Church - which was a massively powerful international organisation.
- Most educated people had been taught in Church institutions and the most highly educated people tended to be members of the Church.
- Many in the Church believed that illness was a punishment for sins - and so the correct response was prayer and penitence (doing things to show you're sorry).
- Medieval culture had an unquestioning attitude to authoritative texts. So old texts were taken to be accurate, even when evidence may have suggested otherwise.
- The Church did play a role in caring for the sick. Medical care for the poor often came from hospitals set up by monasteries.
- Famous hospitals like St. Bartholomew's and St. Thomas's in London started life as monastic establishments.
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- By about 1100, versions of the works of Galen and Hippocrates were coming back into Western Europe bit by bit. Arabic texts based on them, especially Avicenna's Canon, were being translated into Latin in Spain and Italy. The crusades had also made Europeans aware of the scientific knowledge of the Arabists.
- About the same time medical schools began to appear in Western Europe, starting with the one in Salerno, Italy. This taught both men and women and had some women professors. Translations of the Arabic versions of Galen and Hippocrates were accepted as the truth.
- Medieval doctors based their diagnosis and treatments on the theory of the four humours. The theory developed into a more and more complex system, taking in the seasons, the stars, different types of food and clothing.
- Being a doctor meant having studied and learnt from the key ancient texts and the Arabists. This was more important than being experienced in treating people.
- Other 'healers' such as apothecaries, who could effectively treat some diseases, but who didn't have such good understanding of the 'theory', weren't as highly regarded.
- Although human dissection was carried out in the medical schools, it tended to be interpreted in line with the theory of the four humours - although some later medieval doctors began to challenge the traditional understanding of anatomy.
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Medieval Medicine Developments
- More and more schools sprung up (Montpellier, Bologna, Padua, Paris) and human dissection gained acceptance. Debates and new research led to some doubts about the classical texts.
- Some new techniques were developed including diagnosis by urine samples. Colour and taste were used. This is a good aid to diagnosis, which is why doctors still ask for urine samples from patients today - although modern doctors don't have to rely on taste for analysis.
- Doctors also believed that the stars caused disease and relied heavily on astrology in making diagnoses and deciding on treatments.
- In tenth century England, one of the Laws of King Edgar allowed women to train as doctors.
- As medicine re-emerged as a specialised and high status profession with guilds, it became a male preserve. The Guild of Surgeons got this Law of Edgar revoked in the fifteenth century.
- The College of Physicians was founded by King Henry VIII in 1518. It licensed doctors, controlling who could officially practise in London and later in the whole of England. Prospective members had to pass an oral exam to join.
- Only rich people would have had access to the latest treatments and improvements so poor people in the countryside would probably recieve the same treatments that their grandparents would have got.
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Healers and Superstition
- Trained doctors were very expensive. Much of the medicine practised amongst the ordinary people was provided by monasteries, apothecaries and housewife-physicians, using traditional cures (such as bleeding) and experience as their main tools.
- The Church had access to the Latin texts used by doctors. Religious orders, especially the Hospitallers, were devoted to healing. The Church set up some public hospitals, both general and specialised (e.g. maternity hospitals and leper hospitals) - but there were never enough.
- Apothecaries sold drugs and medicine - and sometimes advised on their use. The influence of wise-women herbalists on the apothecaries led the Apothecaries' Guild to admit women.
- The term housewife-physician covers quite a range of people from 'wise women' to the lady of the manor, who was often expected to provide medical help and advice to those families on her husband's lands.
- Medieval people believed that pilgrimages to holy shrines - mainly sites containing the remains of saints - could cure illnesses. Holy water from shrines was thought to help cure sickness. Many people still go to similar sites like Lourdes hoping to be healed.
- Many doctors had magical and superstitious beliefs - saying certain words when administering treatment. Doctors continued to consult the stars.
- Quacks were people without any real medical knowledge who sold medical treatments - that often did more harm than good. They'd sell their wares at fairs and markets.
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Anatomy and Surgery
- Unlike today when surgeons are the most respected doctors, medieval surgery was held in such low regard that many procedures, like tooth-pulling, were often left to low paid assistants and untrained barber-surgeons (i.e. the local barber).
- The dissection of corpses as teaching aids began in about 1300 and slowly brought standards of anatomy back to Roman levels and beyond - but progress was slow as the assistants who carried out dissections were required to find what the books and their betters told them to, rather than anything new and different.
- Surgical treatments were still few and simple, as pain, bleeding and infection made major surgery risky.
- Attempts were made at both antiseptics and anaesthetics, but they were not widely adopted. No notion of infection by germs existed. The use of wine as a mild antiseptic by Hugh of Lucca and his son Theoderic in the early 13th century was prompted by empirical observation (they just noticed it worked). A recipe for an anaesthetic by John of Arderne in 1376 including hemlock, opium and henbane (a relative of deadly nightshade). In carefully controlled doses this may have worked - but was very likely to kill.
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Non-existent Public Health
- As towns and cities began to reappear they lacked the Romans' central organisation and the willingness of the wealthy to provide water and sewerage.
- Only the monasteries made much real effort to provide clean running water and effective toilets. Even the wealthy in the towns had to rely on inadequate cesspits and adjacent wells - or water courses that were little more than open sewers. Those without a cesspit frequently disposed of waste into the street in the hope that it would wash away.
- People found it healthier to drink wine and beer or buy water brought in on pack animals from outside the towns. Most wealthy houses and monasteries brewed their own beer - providing large quantities of low alcohol 'small beer' for servants. The brewing process involves boiling, which sterilises the liquid.
- Some town corporations (councils) tried to regulate against the most disgusting practices. But without real understanding of the risks, there was little will and less financial support to do anything effective.
- Medieval towns were filthy but in most cases nothing was done.
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The Black Death
- The Black Death was a series of plagues that first swept Europe in the mid 14th century. Two illnesses were involved: pneumonic plague, spread by coughs and sneezes (airborne) and bubonic plague, spread by black rat flea bites. Black rats were carried overseas by ships.
- Black Death arrived in Britain in 1348. Its victims were struck down suddenly and mostly died. Between a third and a half of the population were killed. From 1347-1351, 75 million people died from it worldwide. Later outbreaks included the Great Plague of London in 1665.
- This devastation affected the labour market and patterns of land ownership. It affected the ability of the country to raise armies. It changed use of farm land. It was partly responsible for the abandonment of some villages.
- Bubonic plague was the first to strike in 1348. Sufferers were hit by exhaustion, headaches and a high temperature. This was followed by the rise of big swellings in the groin, armpits or the neck - these are the buboes, which give the disease its name. Some survived the disease, but many died around a week after first being infected.
- The plague turned into the pneumonic plague which is far more deadly. This attacks the lungs - making it painful and difficult to breathe. Other symptoms included coughing up blood. Pneumonic plague kills its victims within a couple of days.
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Effects of the Plague
- People thought the plague was a judgement from God or caused by the planets. Some thought it was caused by foul air. Others looked for people to blame, such as the Jews.
- Many thought the end of the world was near and looked for signs of Armageddon.
- Some people tried to appease the Wrath of God by becoming flagellants, whipping themselves and praying.
- It took a very brave person to help someone with the disease.
- Some doctors and clergymen did try to help and took all the precautions they could think of. Strong smelling herbs were used to counter the foul airs believed to carry the disease.
- All-over suits were worn which might have filtered out airborne germs and provided a temporary barrier against fleas. Ships were made to wait 40 days before landing.
- Medieval Europe was faced with something it didn't understand and something it was helpless to prevent. Since there was no understanding of the cause, not many lessons were learnt - so it's no surprise the plague returned later.
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