Medicine in Christian Europe between the twelfth and fourteenth centuries was transformed by the influx of Arab and Greek medical writings and the growth of universities where natural philosophy became the foundation of medical education. The extent to which such "learned" medicine went beyond the schools to permeate the medical practice of physicians and surgeons and medieval society in general is the theme that ties together most of the essays in Practical Medicine from Salerno to the Black Death. This subject is one that has been neglected by many scholars of the history of medieval medicine, and this book will be a useful addition to the field.
The twelve articles in this collection include: Luis Garcia- Ballester, "Introduction: Practical Medicine from Salerno to the Black Death"; Roger French, "Astrology in Medical Practice"; Jole Agrimi and Chiara Crisciani, "The Science and Practice of Medicine in the Thirteenth Century According to Guglielmo da Saliceto, Italian Surgeon"; Nancy G. Siraisi, "How to Write a Latin Book on Surgery: Organizing Principles and Authorial Devices in Guglielmo da Saliceto and Dino del Garbo"; Pedro Gil-Sotres, "Derivation and Revulsion: the Theory and Practice of Medieval Phlebotomy"; Cornelius O'Boyle, "Surgical Texts and Social Contexts: Physicians and Surgeons in Paris, c. 1270 to 1430"; Danielle Jacquart, "Medical Practice in Paris in the First Half of the Fourteenth Century"; Michael R. McVaugh, "Royal Surgeons and the Value of Medical Learning: the Crown of Aragon, 1300- 1350"; Jon Arrizabalaga, "Facing the Black Death: Perceptions and Reactions of University Medical Practitioners"; Peter Murray Jones, "John of Arderne and the Mediterranean Tradition of Scholastic Surgery"; Monica H. Green, "Documenting Medieval Women's Medical Practice"; Luis Garcia- Ballester, "A Marginal Learned Medical World: Jewish, Muslim and Christian Medical Practitioners, and the Use of Arabic Medical Sources in Late Medieval Spain."
As the preceding list suggests, the development of a learned tradition in surgery is a major theme in many of the articles. Other essays examine the role of blood-letting and astrology in medieval medicine and the relationship of solutions proposed by university physicians facing the initial onslaught of the Black Death to those solutions actually implemented by towns. In spite of the use of the phrase "practical medicine" in the title, readers expecting to find detailed accounts of humble medical practitioners at their daily routine are apt to be disappointed. Although the use of archival material in some of the articles hints at the possibility of future scholarship revealing more about ordinary practitioners, this collection deals largely with the work of medical elites, especially royal physicians and learned surgeons. The broader world of medical practice is revealed only to a limited degree in most articles by the evidence of treatises, commentaries, and legal strictures, although Luis Garcia-Ballester looks at the interactions of Jewish, Moslem, and Christian physicians in Spain, and, in a methodological and historiographical article that will be useful to medical historians and historians of women's work alike, Monica Green explores the challenges of finding sources revealing the medical practice of women. As I will comment later in this review, some of the authors in this volume never do fully link the scholastic ideas they discuss to actual practice. Nevertheless, I wish to emphasize that the ordinary medical practitioner is extremely difficult to find in medieval sources, and the authors in this volume reveal much about the spread of scholastic ideas beyond the universities, which is, after all, their stated aim.
The book emerged from papers presented at a 1989 international conference in Barcelona on "Practitioners and Medical Practice in the Latin Mediterranean, 1100-1350", a fact which may account for some of the collection's greatest strengths and greatest weaknesses. Among the many strengths of this collection is its international nature, including contributors from France, Italy, Spain, the United Kingdom, and the United States. Thus the reader is introduced to a wide range of scholarship not usually accessible to the primarily English-speaking reader. The essays themselves likewise cover many geographic regions and time periods. Although the conference was intended to focus on the Christian lands of the western Mediterranean from the twelfth century to the mid-fourteenth century, the essays in this work include research on England and Paris, as well as Italy and Spain, and at least three extend into the late fourteenth and early fifteenth centuries.
Arguably, a weakness in the book resulting from its genesis as a collection of conference papers is the considerable overlap in subject matter between some of the essays. Although the different treatments of overlapping subjects were in many regards very useful, I was disappointed that neither Garcia-Ballester's introduction nor the articles themselves made any serious attempt to discuss the intersections between the articles, the implied agreements and disagreements, and the implications of their collective conclusions. As there were four editors of this book, and the essays were a product of a conference where the authors and editors presumably had the opportunity to hear and discuss each other's ideas, one would have expected more references to the significance of the work of the other scholars for the work of individual authors. The lack of such discussion was especially apparent considering the large number of articles on learned surgery and the pairs of articles that overlapped significantly, such as those by O'Boyle and Jacquart or Siraisi and Agrimi and Crisciani. In the paragraphs that follow, I will discuss the individual essays in the collection, and will conclude with a few comments on the technical presentation of the book.
Although it lacks analysis of individual essays and discussion of collective conclusions arising from the conference, the introduction by Luis Garcia-Ballester is extremely useful in that it introduces the reader to the intended scope of the book, the current state of research in the field, and some of the issues involved in practical medicine during the period covered by the book, including the means of social diffusion of university medicine, the appearance of a network of medical care, the content and concerns of the "new" learning, and the process of its assimilation. The coverage of these subjects, however, is somewhat uneven. In particular, the lengthy discussion of the various theories concerning the presence in Salerno of medical knowledge based on natural philosophy, which seems to have little direct relevance to the content of most of the articles in the collection, occupies more than half of the introduction. Nevertheless, this introduction is very helpful in introducing the reader to the problems and complexities of the field.
Roger French in his "Astrology in Medical Practice" provides a brief overview of the use in the medieval west of astronodia, a contemporary term embracing both astronomy and astrology, which French claims were indistinguishable in this period. He argues that, while prediction was not a part of western astronodia in the early twelfth century, the absorption of Arab learning and the development of reliable astronomical tables encouraged the incorporation of predictive astronodia into medicine during the thirteenth and fourteenth centuries. As the body was believed to be a microcosm of the universe, examination of the heavens could help the physician predict the outcome of illnesses, prescribe medicine, and perform blood-letting or surgery, although the corrupt nature of the world could result in inaccurate predictions. French hypothesizes that medical men used their knowledge of astronodia to win the confidence of patients and students. While this theory is plausible, the commentaries and other theoretical accounts that French utilizes do little to prove that astronodia actually had a place in everyday medical practice. Reference to some of the practicing astrologers who appear in other essays, especially that of Jacquart, would have helped to support some of French's assertions.
The effect of universities and scholastic methods on the organization and transmission of surgical knowledge are the focus of the next two chapters. Jole Agrimi and Chiara Crisciani use the writings of Guglielmo da Saliceto, a thirteenth-century Italian surgeon-physician, to illustrate the early stages of the integration of scholastic learning and practical experience in "The Science and Practice of Medicine in the Thirteenth Century According to Guglielmo da Saliceto, Italian Surgeon." A teacher and practicing medical man, Guglielmo wrote in the thirteenth century when the old system of training through oral tradition and practice was giving way to more formal educational institutions and written texts. Although his educational terminology, extensive use of ancient authorities, and the fact that he put his knowledge into written form reflect a familiarity with scholastic culture, Guglielmo placed considerable weight on various forms of unwritten medical knowledge, particularly personal experience. Thus, Guglielmo recognized both the validity and the limitations of Greek and Arabic authorities, established local practices, and personal experience. Later scholastic writers, such as Guglielmo's student Lanfranco, would construct a more elaborate hierarchy of knowledge, thus excluding or devaluing certain forms of practical knowledge and informal learning.
Similar themes are explored by Nancy G. Siraisi in "How to Write a Latin Book on Surgery: Organizing Principles and Authorial Devices in Guglielmo da Saliceto and Dino del Garbo." Siraisi compares rhetorical and pedagogical strategies in the surgical works of Guglielmo da Saliceto and Dino del Garbo, an Italian surgeon of the next generation. Siraisi finds that while the works have much in common, they are ultimately separated by Dino's greater integration into the scholastic world, as witnessed by his choice of the commentary format instead of the practical manual; his use of scholastic quaestiones; and the fact that his personal experience, while apparent, is not privileged or emphasized as was that of Guglielmo. Siraisi employs greater skepticism than do Agrimi and Crisciani in her approach both to biographical evidence and to the use of anecdote by Guglielmo. She points out that the recounting of personal experience was not simply another form of knowledge used to amplify and sometimes challenge written learned traditions, but also a tool for competitiveness and self-advertisement. Thus historians must be careful in taking personal anecdotes at face value. Although Siraisi, Agrimi, and Crisciani convince the reader that learned traditions were entering and transforming the practice of surgery during this period, one does wonder how typical surgeons such as Guglielmo, Lanfranco, and Dino really were and whether theoretical opinions were reaching more humble practitioners.
The evolution of theories concerning blood-letting in the middle ages is discussed by Pedro Gil-Sotres in "Derivation and Revulsion: the Theory and Practice of Medieval Phlebotomy." As the title suggests, Gil-Sotres, contrary to the assumptions of Renaissance physicians and modern historians, argues that both derivation (blood-letting near an affected area) and revulsion (blood-letting as far as possible from an affected area) were recommended by medieval physicians, although the practice of derivation was less explicitly described than was the practice of revulsion. Theories and recommendations concerning blood-letting were strongly influenced by the influx of the new learning, especially Galen. Although Gil-Sotres discusses practical recommendations for blood-letting in formal medical treatises, he admits that the authors of such treatises were often far removed from the humble barbers who tended to be responsible for blood-letting by the thirteenth century, and it is impossible to tell how closely they followed learned opinion.
Cornelius O'Boyle in "Surgical Texts and Social Contexts: Physicians and Surgeons in Paris, c. 1270-1430" suggests that the popularity of learned surgical texts being produced in the thirteenth and fourteenth centuries was a response to social and economic pressures, particularly the availability of learned medical education at the universities. Physicians at the University of Paris claimed to possess the true art and science of medicine and thus asserted a hierarchy in which surgeons and apothecaries occupied positions below the learned physicians. Although this hierarchy was never absolute, university physicians did obtain considerable support from ecclesiastical and secular authorities in excluding unlicensed medical practitioners. Surgeons who mostly received their education by apprenticeship were initially excluded from the learned elite. During the thirteenth and fourteenth centuries, guilds of surgeons arose with masters appointed to examine skills of members. O'Boyle argues that this arose at least partly in response to popular concerns about levels of knowledge among surgeons, fueled by the claims of physicians to possess the true art and science of medicine. In order to assert their position as a learned discipline against the barbers and unlicensed surgeons, and because of the need for educational tools and an examinable body of knowledge, surgeons increasingly began to appropriate as symbols of their profession the learned surgical texts written by university physicians such as Guy de Chauliac.
In "Medical Practice in Paris in the First Half of the Fourteenth Century," Danielle Jacquart appears to find less competition between surgeons and physicians than does O'Boyle, arguing that most restrictive legislation was designed to prevent incompetence. Jacquart surveys the practice of surgery, medicine, and astrology in Paris between the late thirteenth century and mid-fourteenth century. Although sources are scant for this period, she argues from legislation and treatises that both physicians and surgeons at this time displayed a concern for professional competence and valued practical as well as learned training. Thus scholastic writers, attempting to establish a learned tradition for surgery similar to that which existed for medicine, valued and promoted traditional practical training for surgeons as well as study of ancient authors. Similarly, practical training was enforced for physicians. Surgeons, as well as physicians, were valued and patronized by the kings of France. Jacquart finds that astrology appears to have played only a small role in Parisian medicine, apart from the royal courts where some physicians appear to have specialized in astrology, a skill that would have had political as well as medical implications.
The growing importance of the learned surgeon in the fourteenth century, a theme mentioned by several of the preceding authors, is fully illustrated in Michael R. McVaugh's "Royal Surgeons and the Value of Medical Learning: the Crown of Aragon, 1300-1350." In this chapter, McVaugh traces the activities of a surgical dynasty at the court of Aragon. The family of surgeons enjoyed royal patronage for several generations, performing court functions as well as surgical duties. What is striking about this family is that, although they were known as surgeons, they were clearly reading and translating the learned authorities (at least one had attended a university) and performing medicine beyond surgical intervention. From these and other contemporary examples, it is clear that a distinct line was not always drawn between medicine and surgery. McVaugh argues persuasively that surgeons were encouraged to pursue medical learning by the greater favor and patronage that such learning brought them. The brief glimpses of physicians at work yielded by McVaugh's archival research are a refreshing change from the largely prescriptive sources often utilized by other authors in this collection.
Jon Arrizabalaga in "Facing the Black Death: Perceptions and Reactions of University Medical Practitioners" examines the theories and solutions developed by university physicians in the regions surrounding the Latin Mediterranean upon their first contact with the Black Death. Many of these works were written not for academic audiences, but to educate or provide help to the populace. Arrizabalaga argues that, contrary to the widespread historical view that a great separation existed between the theoretical ideas of academics and the practical solutions of the populace, the health measures implemented in western cities reflect a popular acceptance of university medicine and natural philosophy. Although many contemporary university physicians blamed the plague on corruption of the air, they also believed that the contagion, once begun, would spread from person to person. Thus they suggested higher standards of cleanliness, a moderate way of life, and an avoidance of personal contacts with those afflicted by the plague -- suggestions which embrace most of the preventative measures adopted by towns according to Arrizabalaga. The essay focuses almost exclusively on the academic theories, and I would need to see far more discussion of the popular beliefs underlying urban legislation before I would be fully convinced that the latter resulted from popular absorption of scholastic medicine. Nevertheless, Arrizabalaga convinces the reader that popular and academic theories were not entirely antithetical and may very well have been closely related.
The theme of the learned surgeon is returned to again in the chapter by Peter Murray Jones, "John of Arderne and the Mediterranean Tradition of Scholastic Surgery." Jones argues that scholastic surgery reached England in the fourteenth century only in the form of manuscripts, not in the person of university trained surgeons. Thus John of Arderne's treatises take a different form than those on the continent. Although probably not university educated, John of Arderne, a practicing surgeon, was clearly well read in scholastic literature. Even though he borrowed the contents of scholastic treatises, he ignored their standard structure and wrote remarkably detailed instructions precisely describing diagnosis, instruments, and techniques. Jones suggests that this format was well suited to England where readers would have little opportunity to witness operations by learned surgeons and needed more detailed instructions.
The chapter by Monica H. Green, "Documenting Medieval Women's Medical Practice," is a delightful anomaly in this volume both because of its lack of discussion of the impact of scholastic medicine (Green devotes one paragraph to the subject) and because of its historiographical and methodological focus. This chapter is likely to be of interest both to specialists and non-specialists in the history of medicine. Green's in-depth discussion of the issues involved in locating records of women's medical practice will benefit anyone interested in studying women's work. Green explores some reasons why we have so little knowledge of medieval women's medical practice, and medieval women in general, including among many other issues: different patterns in women's careers, women's exclusion from many aspects of public life (and thus from many documents), the tendency for women to be known by the names of husband or father rather than by occupation, and the assumptions and preconceptions of modern historians which lead us to ignore or distort female medical practice. Green argues that more evidence of women's medical practice can be found, but historians will have to be more creative and thoughtful in their approach to the evidence. Green illustrates her assertions by an analysis of the strengths and weaknesses of several studies revealing female medical practitioners. Many of the questions raised by Green cannot be answered at this time, but they are questions that every historian should be aware of.
The final article in this collection, Luis Garcia-Ballester's "A Marginal Learned Medical World: Jewish, Muslim and Christian Medical Practitioners, and the Use of Arabic Medical Sources in Late Medieval Spain," departs from the world of Christian learning to examine the work of Jewish, Muslim, and Mozarabic physicians in the Iberian peninsula and their use of Arabic medical manuscripts. Garcia-Ballester finds that Jewish physicians, although barred from universities, were particularly active in the acquisition of Arabic manuscripts and the production of their own learned works, attaining an intellectual tradition equal to, although different from, that of university physicians whom they sometimes admired. Jewish medical practitioners applied their considerable learning in Greek and Arabic scholarship to the needs of the towns in which they worked, tempering the recommendations of the ancients with knowledge gained through practical experience. I found this essay, with its wide array of sources including many archival documents, to be fascinating and look forward to the larger study of medicine and Jewish practitioners in Aragon that is promised by Gargia-Ballester and McVaugh.
Readers of Practical Medicine from Salerno to the Black Death would have been aided by the inclusion of bibliographies either at the end of each article, or at the end of the book. Similarly, a more comprehensive index would have been helpful. The existing index concentrates mostly on proper names and neglects topics like midwife, childbirth, and phlebotomy. In spite of these drawbacks, Practical Medicine from Salerno to the Black Death is a very useful collection that will introduce the reader to a wide range of subjects.