The main flaw in the monumental labour of Hippocrates was that he had insufficient data from which to draw valid conclusions. He deduced, for instance, that spells of warm, moist weather were, in themselves, conducive to ill health; a thesis reasonable enough where malarial regions were concerned but irrelevant if not positively misleading when applied to England. His great achievement was to have provided a blue-print for research on which subsequent generations should have worked. The tragedy is that the vast compilation of case histories, on which a serious study of epidemiology could alone have been based, was not made by his successors. After the death of Hippocrates in 377 BC, medical science slumbered for five hundred years; it awoke only to find itself rigidified by the misplaced formalizing genius of Galen of Pergamos.
Galen was one of the outstanding intellects of his age and a great experimental physiologist. But, when it came to epidemiology, rather than work from the Hippocratic base and accumulate fresh data from which empirically to establish new and constructive theses, he instead elected to devise an inflexible theoretical pattern which left no room for further research or original thought. He lived through a major epidemic of bubonic plague but the phenomenon was in no way reflected in his work. To attempt to summarize Galen’s complicated and, within his own terms of reference, logically faultless theorizing would be to reduce it to a parody. Suffice it to say that he believed ill health to depend on the interaction of temperament, the constitution of the atmosphere and certain other factors such as excessive or ill-judged eating and drinking. Temperament and constitution in their turn depended on the blending of the elementary qualities and any failure to achieve perfect balance led to one of a number of possible discords. The permutations on these factors were developed into an intricate mathematical pattern: a computer into which the details of any case could be fed and a logically satisfactory explanation provided.
Unfortunately, though the logic might be impeccable, its relevance to anything so mundane as the prevention or cure of plague was sadly tenuous. What was worse, the medieval physician believed that Galen had said the last word on epidemics and that any further research was unnecessary if not positively disrespectful to the teachings of the master. And yet the teachings of the master themselves were in doubt since the original texts had been largely lost and doctors in the West for several centuries worked almost exclusively from inadequate Latin versions of Arabic translations of Hippocrates and Galen. The result was an Arabic-Latin literature, in Dr Singer’s description,
…generally characterized by the qualities most often associated with the words ‘medieval’ and ‘scholastic’. It is extremely verbose and almost wholly devoid of the literary graces. An immense amount of attention is paid to the mere arrangement of the material, which often occupies its author more than the ideas that are to be conveyed. Great stress is laid on argument, especially in the form of syllogism, while observation of nature is entirely in the background…. Lip-service is often paid to Hippocrates, but his spirit is absent from these windy discussions.{122}
Nurtured on such material it is hardly surprising that medical science did not flourish in the Middle Ages. ‘The Dark Ages for Medicine,’ wrote Dr Singer, ‘began at the death of Bede in 753’.{123} They did not end until long after the Black Death had run its course. But the failings of the fourteenth-century doctors should not be exaggerated nor their limitations presented as grotesque extravagances. Ill-informed and unimaginative they might have been but there was, on the whole, surprisingly little of the:
which were the stock-in-trade of Chaucer’s alchemist.
The situation of medicine was not helped by the stern determination of the medieval churchman to keep the physician in his place. What Professor Gurlt described as ‘that fatal exaggeration which enthroned theology not merely as mother but as Queen of all the sciences’,{124} ensured that the doctor would play a secondary role. In the sick room it was the priest who took the lead and the doctor who humbly offered his services once the praying was over. Before he even treated a patient the doctor was supposed to establish whether he had first confessed; if he had not, then medicine would have to wait its turn. Sometimes the doctor would manage to assert himself but, in general, the more eminent the invalid, the more likely it was that he would find himself thrust into the back row behind a bevy of churchmen and courtiers. When the disease worked quickly a doctor might not even be admitted to his patient’s bedside until death was imminent or had actually occurred.
But the Church, by the stranglehold which it had on every field of education, ensured that the invalid would have gained little even if the doctor had been given a freer hand. All medical teaching at the universities was on lines laid down by the Church and consisted mainly of the reading of outmoded texts with a brief and usually misleading ‘interpretation’ by the professor. Surgery was the poor relation of an anyhow impoverished science. In 1300, Boniface VIII published a Bull forbidding the mutilation of corpses. His object was to check the excesses of relic hunters but, incidentally, he dealt a crippling blow to would-be anatomists. Soon afterwards the Medical Faculty of Paris formally declared itself an opponent of surgery. At Montpellier, supposed to be among the most enlightened of the medical schools, there was one practical anatomy lesson every two years. This long and eagerly awaited occasion consisted merely of the opening of an abdomen and a cursory exposition of its contents. It was not till the end of the fifteenth century that Sixtus IV authorized the practice of dissection and even then specific authority had to be obtained on each occasion.
Given such handicaps it would have been miraculous if the medical profession had met the Black Death with anything much more useful than awe-struck despair. Their efforts were as futile as their approach was fatalistic. Not only were they well aware that they could do little or nothing to help but they considered it self-evident that an uncharitable Deity had never intended that they should. ‘The plague’, wrote Gui de Chauliac, one of their most distinguished and, incidentally, successful practitioners, was ‘shameful for the physicians, who could give no help at all, especially as, out of fear of infection, they hesitated to visit the sick. Even if they did they achieved nothing, and earned no fees, for all those who caught the plague died, except for a few towards the end of the epidemic who escaped after the buboes had ripened.’{125} A doctor not prepared to visit the sick must, of course, labour under a singular disadvantage but de Chauliac was certainly right in his contention that, from the point of view of the infected, it made little difference. Nothing in the medical literature which survives suggests that the treatment of the doctors, though it may sometimes have eased a patient’s sufferings, can have been directly responsible for a single cure.
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