“Changes in Medical Practice During the
High Middle Ages in Paris”
The well-being of the human body is the central concern of medicine; therefore, the image of the body is one of its essential concepts. The major purpose of this presentation is to examine the changes in medical practice, especially in Paris, resulting from changes in the image of the human body in the 11th to 14th centuries, the High Middle Ages, when medicine became an independent discipline separate from philosophy at the University of Paris. The University began to issue medical licenses and previously low ranking surgeons were elevated to the status of doctor surgeons. The developing importance of scholastic philosophy in Paris was probably the foremost of the multiple complex causes of those events that influenced the manner of medical practice. Others were the rise of universities in Europe, the arrival of Aristotle’s work in the Latin West, the transfer of Islamic medicine to the West, and the changing societal and economic structures, especially those accompanying the increasing population.
Scholasticism is both a method of learning and creating ideas and a doctrine that played a pivotal role in the cultural developments of the time and thus bridged Antiquity to the Middle Ages. Historically, that unprecedented intellectual movement was spearheaded in Paris by the Dominican monk, Thomas Aquinas (d.1274). Scholasticism influenced theology, philosophy, architecture, and literature as well as medicine. Thus, the changes in medicine were integrated with other cultural changes. Before then, medicine was essentially an intellectual, verbal gymnastic; but, as part of the scholastic movement, it became a human-centered discipline that emphasized the care of the human body and along with the dynamic cultural forces that were occurring brought about a radical change in the image of the human body.
Before the High Middle Ages, European culture was an extension of Greco-roman culture and was embedded in Christian thought, especially the neoplatonism advocated by Plotinus (d.270) and St. Augustine’s (d.430) Christian doctrines. The ultimate nature of reality was seen as spiritual and immaterial and there was an antithesis between the soul and the body. People were indoctrinated to believe that the human body with its senses was evil, covered by corruptible flesh and riddled with sin. St. Augustine wrote: “From the body itself arise so many diseases that not even the books of doctors can contain them all . . .(and) the treatments and drugs themselves are painful. Thus, men are rescued from a penal destruction by a penal remedy.” Pope Gregory the Great (d. 604) asserted that the 6th Century plague epidemic was the result of communal sin.
That image of the ‘fallen man” was transformed by scholasticism with its separation of mind and body, faith and reason, soul and the body, and by the views of Aristotle, the great synthesizer, who maintained that ‘there was nothing in the mind that was not first in the senses”. Thus, the image of the body was elevated and its ongoing ontology established—a remarkable intellectual awakening!
Aquinas had been influenced greatly by Aristotle and by such Islamic philosophers and physicians as Avicenna (d.1037) and Averroes (d.1198). During the High Middle Ages, many of the classical Greek and Islamic texts were translated; Aquinas’ friend, William Moebeck, translated Aristotle’s text and Stephen of Antioch translated medical works in 1114. Such texts were the cross-cultural intellectual fertilization that propelled scholasticism.
The rediscoveries of Aristotle’s works and the arrival of Islamic medicine in the West played a vital role in the reassessment of the image of the human body. Aristotle maintained that knowledge began with sensory experience of the world and Islamic thinkers held that the body, the organ of the senses, was not evil, but a gift of God. Thus, both the body and soul were God’s creation and the body was the embodiment of the soul. In 1215, Pope Innocent III approved Transubstantiation for the first time even though it had been a practice in Holy Communion for a thousand years. In the same year, King Philip II of France chartered the University of Paris and medicine became an independent discipline. Between the 11th to 14th centuries, many universities were started in Europe and the new ideas of the body and health facilitated the formation of medical departments in those universities. Thus, there was an analogy between developments in religious and in medical history.
The curriculum in the new medical departments was influenced by Aristotle’s “Natural Science”, Avicenna’s “Canon of Medicine”, and Averroes’ “Commentaries”. As part of the sweeping changes that were occurring, medicine developed with two divisions: 1) Theory, that included physiology, etiology, and symptomatology, and 2) Practice, that was subdivided into hygiene and therapy.
The new teaching by medical masters emphasized “man was liable to be ill, but capable of recovering good health and maintaining it by human resources that depended on the activity of man.” Thus, we can see that there were revolutionary developments in the concepts of medicine and a shift in the intellectual mood from myth and the sacred to the realistic and the secular. People began to question the belief that disease was sin made visible by God’s will.
The development of the University of Paris and changes in medical practice were influenced strongly by the medical school in Salerno in Southern Italy that probably was started in the 9th century. Many Salerno clerics and the famous “women of Salerno” were known for their medical skills. Also, its location in the southwestern tip of Italy exposed it to many multicultural influences and it was near the celebrated intellectual center, the Abbey of Monte Cassino, where Constantine Africanus (d.1087) translated Arabic medical works into the Latin, “The Corpus Constantinum”. There were important events in the history of medicine; it became Greco-Islamic not completely Greco-Roman. Also, the “Antidotarium Nicoli”, written in Salerno for physicians and apothecaries, became the most influential medical text in medieval literature.
Many translated Latin medical texts from Salerno were available in Paris. It was becoming an important intellectual trove during the High Middle Ages when many societal changes were taking place, especially the marked increase in population that doubled from the year 1000 until the plague in 1347. Also, there was a commercial revolution, a booming economy, new market towns, and new classes of merchants and artisans as well as an increasing supply of scholars trained in law, theology, and medicine. Virtually every facet of knowledge and belief were reinterpreted. Wealthy merchants sent their sons to the university. There was interest in the well-being of the body and the pleasures of life on earth as the new image of the body was symbolically elevated and the practice of medicine became a social enterprise.
In Paris, with its population of 200,000 in 1310-1320, there were 84 physicians, 26 mater-surgeons, and 97 barber surgeons. Ambitious young men saw the expanding marketability of the medical professions and students rushed through their training to become practitioners. The demands for medical education became so great that a Canon of Notre Dame and a contemporary set up their own school of medicine. Until then, many practitioners had had no medical training. However, the new social classes wanted the new “Aristotelised” doctors and were willing to pay for conclusive results. New medical faculty and learned doctors petitioned for professional status and protection. Pope John XXII, the only physician pope in history, requested the Bishop of Paris to support the medical faculty and enforce the law stipulating that the practice of medicine was limited to masters of the university and others who were licensed. In 1331, Philip VI put forth a royal edict that allowed the faulty to issue medical licenses. Consequently, educated medical doctors established a firm position in society, but the status of surgery was much more complicated.
During the Gregorian Reform (about 1073), churches forbade monks to practice the art of healing; the care of the sick was left to the secular clergy or to lay people. A hierarchy in the medical profession was established; the manual work of healing (e.g. surgery) was left to lay people. In his influential 1306 book, Pierre Dubois described the ideal medical education; the medical curriculum should be taught only after studies in natural philosophy were completed. But, about surgery, he wrote: “Those who are less accomplished in their studies, after having acquired a little knowledge of logic, and more if possible of medical science, will learn the surgery of men and horses”. Thus, he was adhering to the old view that manual work had lower status than work involving abstract reasoning.
The result was constant conflict between the physicians and surgeons. Lancfranc of Milan, an outstanding 14th century surgeon, wrote: “O God, why is there now such a great difference between physicians and surgeons…Physicians have given up the conduct of operations to laymen…Ordinary people now think it is impossible for the same man to have mastered both surgery and medicine.”
Surgery reached its nadir in 1163 when the Council of Tours pronounced, “The church does not shed blood.” Surgical books disappeared from the university library and most surgical procedures fell to the hands of barbers, bath-keepers, and hangmen. In 1350, Adam Francovile, Dean of the medical faculty at the University, ordered that all new Bachelors of Medicine must take an oath not to practice surgery.
In Italy, however, technical writing about surgery appeared in the late 13th century and soon thereafter at Montpelier and at Paris a little later. The Italian doctor/philosopher, Pietro d’Adano, wrote: “Some people alleged that the only part of medicine that offered any certainty was surgery because it alone yielded obvious results.”
In Paris, among intellectuals and educated medical doctors similar sentiments began to prevail as there was increasing dissatisfaction with the unsuccessful results of many medical treatments. A letter written by the Abbott, Peter the Venerable of Cluny about 1156 to his doctor stated: “I have used the diet and medicines (medical practitioners) recommended for almost three months already, but up to now, I feel very little, indeed scarcely at all better”.
People also began to scorn Doctors’ verbosity and their arrogance in using the names of Hippocrates and Galen. The outstanding surgeon, Henry de Mondeville (d.1320), wrote: “The doctors do not inspect the urine out of necessity, but just in order to look as if they are doing something. Doctors know nothing and do nothing except talk at their patients without discrimination”. Thus, the mood clearly started to favor surgeons and they, like other craftsman, organized fraternities and guilds to protect their livelihood. In 1250, the Provost of Paris appointed six surgeons to examine all practitioners of surgery. In 1310, the Provost, forbade 29 barber surgeons to practice surgery unless they had been examined by Masters of Surgery and, in 1311, King Philip VI, who understood the value of surgeons’ help during war and in the maintenance of public order, required all male and female surgeons to be examined and approved by a royal surgeon. Soon, there were three groups of surgical practitioners: master surgeons, licensed surgeons, and lay people. St. Louis, now regarded as the holy founder of surgery, began the College of Cosmos that was named for the patron saint of surgery.
But, for doctor-surgeons, the image of the human body started to become grandiose. The different zones of the human body, the microcosm, began to be framed in relation to the universe, the macrocosm—a belief that we influenced by the master of the Cathedral School of Tours between 1145 and 1153. Thus, the body was often seen as a map or as a cosmological schema. Also, Moslems held that events in the celestial body influenced the happenings in the terrestrial body, the human being. Thus, astrology and astronomy played an important role in medicine.
Henry de Mondeville, surgeon for Philip IV, wrote the famous book, Chirugia, that emphasized the relationship between nature and the human body. Gui de Schauliac, a monk, who was the private surgeon for the Aviginon Pope, Clement VI, defined surgery as “A set of manual operations whose subject is the human body; therefore, surgery is indeed true medical knowledge”. His book, Chirugia Magna, was translated in many different languages and used as a surgical textbook in Europe for centuries.
In conclusion, during the High Middle Ages, the image of the human body was elevated. The time for the celebration of the body had arrived and that development led to changes in medical practice—it started to become a human-centered, value-laden social enterprise.
Presented at the November 2001 meeting of the Innominate Society.
Edited by John J. Schwab, M.D.
Typed: December 3, 2003