Transcript: 281. Monica Green on Medieval Medicine

Note: this transcription was produced by automatic voice recognition software. It has been corrected by hand, but may still contain errors. We are very grateful to Tim Wittenborg for his production of the automated transcripts and for the efforts of a team of volunteer listeners who corrected the texts.

Peter Adamson: We are going to be talking about medieval medicine. And let's start with what I think is a very basic question of how we know anything about medieval medicine. There are quite a number of surviving treatises on medical subjects. So that's obviously one body of literature that we can draw on. But I know from reading your work that you also think historians of medicine should be drawing on a wider range of texts. So for example, you mentioned legal treatises. And we can probably also learn something about medieval medicine from artifacts of physical things like say talismans or even medical instruments. So there's probably a lot you can say here. But could you give us some kind of idea of the range of sources that we can draw on as historians here?

Monica Green: Certainly. One of the things I'm trying to do is persuade general historians that the work of telling the story of the history of health and the history of disease is everybody's job. Everybody who ever lived had a body. Probably most people who ever lived had something go wrong with their body at some point. They stubbed their toe, they had a cut, and then the whole range of other kinds of disease. So health is an issue that affects everyone and it's certainly a concern for a lot of people in terms of the choices they make about how to live their lives. So as something that's pervasive in society, basically almost anything can be used potentially as a source to tell us something about ill health, about attempts to preserve health when it's already there, and to alleviate conditions when something about the body goes wrong. The medical texts that you refer to, they're the low hanging fruit just because their relationship to medicine is so obvious. And in that respect, we haven't even touched a fraction of the material that's out there in terms of finding these sources, identifying what they are, where they came from, who wrote them, how they circulated, and then what their content is in terms of the actual ideas they're carrying forward about medicine, about the humors, about the structure of the body. So there's that entire range. And as I said, they're the low hanging fruit in the sense that they're readily identifiable. Finding other kinds of sources is more of a challenge for the simple reason that their medical content won't necessarily be flagged. So when an archivist is describing some document, they will describe who it's written by, who it's written to, the date, place, basic sorts of things. But they won't say that, oh, in this letter, you know, King X was telling his advisor about, you know, 'please acquire these other kinds of medical ingredients for me because I have need to treat my gout.' So there's ways in which medical concerns might be represented in the documents. But unless we're experts in that particular archive, we won't know that. We won't have that level of detail. And so you mentioned legal sources - the one legal source that I have used in detail was actually brought to me by another historian. So the other historian had already found it and he consulted me about it. And basically, we worked on it together. He as a legal historian and I as a medical historian, trying to work through the case of - I mean, and it was an amazing case of a midwife who was accused of murder of one of her patients and really can get into great levels of detail where this was the one of the many things that were fascinating about it. You really have to go into what were the conceptions of the physiology of the female body. This was a case of childbirth where the woman had given birth to her child by a first midwife, who was already present at the birth, but then the placenta was retained after the birth. And so a second midwife was called to help with a retained placenta. And then the woman, the new mother died soon after that. But the point is, is that we had to go through all of the ideas about the retention of the placenta, how risky was it, and to what extent fault can be laid at the door of a medical practitioner. I mean, this is still a period where there aren't very well developed ideas about medical malpractice, but clearly there was debate and that was the context of this trial: Is this a case where the woman would have died anyway? Or is this a case where some bad decision or maybe even malicious activity had gone on? So, but again, we don't know how many other such cases like that might be out there. There's just thousands of archives.

Peter Adamson: I guess the listeners would not forgive me if I didn't ask you whether she was found innocent or guilty.

Monica Green: That's the thing. It's only a partial document that we have. And well, we speculated, but we don't know. The quick answer is, is we don't know. The other complication with that case is the woman who died was Christian, and the midwife who was accused of murder was Jewish. And so part of the contextualization that we had to do in that case was look at what were the attitudes, and what was the experience of Jewish-Christian relations in that town. So it was not a pretty picture.

Peter Adamson: That's fascinating. Actually, that sort of leads on to the next thing I was going to ask because since I work on Islamic philosophy, I know that there's a lot of influence from the Islamic world, including Jewish authors, but also Muslim authors like Avicenna on medieval medicine in Latin or in Latin Christendom. And I'm wondering, since I know that they knew Avicenna, for example, very well, I'm wondering whether these sources from the Islamic world even dominate in the medieval period. I mean, how well do they know, let's say, Hippocrates and Galen? Or do they even get most of their Galenic medicine indirectly over authors like, say, Avicenna, Averroes, other authors from the Islamic world?

Monica Green: That's such a wonderful question. And it's a question that has driven a lot of work in the intellectual side of the history of medicine - which parallels a lot the history of philosophy, and also the history of science - is looking at texts, looking at the development of theoretical concepts, and then looking at the transmission of those concepts both within linguistic traditions and across linguistic traditions. So the phenomenon, first of all, the phenomenon of translation in medicine parallels the translation of scientific texts and to an extent parallels the translation of philosophical texts. What I'm realizing is there are some interesting differences, is that we more or less assume that those things are happening at the same time and pretty much in the same places. And what I'm realizing with medicine is that medicine seems to be happening earlier and separately from the other intellectual traditions. So one of the people I'm working on now is someone named Constantine the African. He is an immigrant to Italy. He's from North Africa, probably from the area that today we call Tunisia. And we don't really know the circumstances of why he left Tunisia, why or how he came to Italy. But certainly he came, and he first goes to the coastal town of Salerno, and then goes to the monastery of Monte Cassino, which is just south of Rome. And he spends the rest of his life there translating works from Arabic into Latin. The work that he's doing in translation precedes the main period of translation of scientific texts by almost a century.

Peter Adamson: And also philosophical texts, actually.

Monica Green: Yes. And he's been the biggest mystery in all of this. I mean, again, as I just said, we don't know his motivations. The fact that he comes to Monte Cassino, at this time the monastery where he's at, is the foundation of the Benedictine order. And it is one of the most amazing places. And during the period that he's there, it's the site of an amazing investment in renewal and rebuilding the site of the monastery. There's an amazing new basilica that is opened in this period. And the library is growing. And one of the things that we're learning about what Constantine was doing is we've always seen him as a translator from Arabic into Latin. You know, as if it's just kind of this two point, from point A to point B, and then that's all that's involved. What we're realizing now is that even before Constantine arrived, somebody at the monastery, we don't know who, is already going through older Latin works in medicine, is collecting a lot of these things and is editing. I mean, comparing two or three different copies of a text and trying to find out, 'okay, do we have even a good text in front of this? Have we correctly transcribed these Greek words or translated these Greek words?' So there's a tremendous amount of editing work. And in a topic as technical as medicine, editing work necessarily involves analysis. It's not going to be immediately obvious to you which of two alternatives of a spelling of a word is the correct one, because you have to figure out what the word means. You know, what physiological process is this referring to, or what part of the body is this referring to? So the work of translation is much more contextually nuanced than we thought. 
Then there's a secondary question. So we can say, and we're understanding better now, what is actually going on at Monte Cassino and the tremendous amount of intellectual work, and not just technical rendering, that's happening. The next question is, okay, well, what is the larger impact of that? It's one thing to say, okay, in the context of this one monastery, there's discussion, there's translation, there is a circulation of text. Why does anybody else pay attention to it? Why does anybody copy this work? Why does anybody transmit this work? And something that I've had evidence for for a long time, but it just kind of keeps repeating itself, is things that we know were composed in Southern Italy - in many cases, we find them in England 10 years, 20 years later. Those are maximums of how long that it takes to get there. That's simply, it's showing up in manuscripts in these distant places. Germany, the same thing. We know that these texts very quickly got disseminated to Germany. We know that they very quickly got disseminated to France. So what we have, the phenomenon that we have, is that Constantine was rendering this Arabic material into Latin, but almost immediately it then becomes Latin medicine. Not simply in the sense of it's being written in Latin, but that it's being absorbed, read, commented on by individuals at a variety of different intellectual centers throughout the continent. So it's amazing. 
But to go back to your initial question about Avicenna: Avicenna also is translated in the 1150s, 1160s, 1170s perhaps. He does not have that same immediate impact as the works that Constantine translates. So that's part of the work that I've been doing is to assess why certain things are adopted readily and circulate widely and other things disappear. I mean, even though we know when and where they're translated, they have no immediate impact.

Peter Adamson: And how much of a difference does it make that these works are being rendered into Latin? So if you've got both Greek and Arabic sources in medicine, justice, and philosophy coming into Latin, do they make a lot of medically significant decisions in terms of how to, for example, render technical terms into Latin?

Monica Green: Oh, everything - every word that's being translated is a decision that has to be made. Are you trying to find a Latin equivalent for the word, whether it's Arabic or Greek? Do you have to coin a new word to try to render this? Do you just transliterate? So taking an Arabic word in Arabic letters and just putting it into Latin letters without changing the word. And then once you have a sentence that you've put together, does it make sense? Is it comprehensible? Very few of Constantine the African's translations have been critically edited. So we have very little, and even though in many cases we know what his original Arabic source was, hardly any of these texts have been compared side by side of the original Arabic with the Latin. And so there's not a lot of work that's been done about how he was making those decisions and what the normal pattern of translation was.

Peter Adamson: By the way, the Arabic texts probably aren't very well edited either.

Monica Green: Well, yeah, that's the other side of the story. And in some cases, at least in terms of the surveys that have been done thus far, the original Arabic hasn't been identified. It may not have survived to the present day.

Peter Adamson: I'm actually in a period of the podcast, which is much later now - I've been doing the 14th century. And one of the things I've been talking about in the past few episodes is the extent to which 14th century science, or physics especially, anticipates breakthroughs that we associate more with modern physics. And so I'm wondering to what extent we can say that also about medicine. I mean, do they actually make discoveries or advances in the medieval period on the medical front that we would consider from our point of view to be steps forward? Or are they just kind of reworking the Galenic medical approach? How do they sort of come out as scientists from our point of view?

Monica Green: That's a kind of question that I usually try to avoid. I mean, that implicit comparison. No, there's two things. There's the comparative element on the one hand, and then there's the kind of the teleological element in the other in the sense of 'can we find direct connections between what happened in the 14th century and the present day?' So it not simply has to have happened in the 14th century, but it has to have persisted in subsequent centuries and very, very different contexts. In part, we can give a positive answer to those questions. And I don't work on the 14th century in terms of medical theory. There's some other work that I've been doing on the 14th century, but from a very different perspective. But some things that I would point to that we can say: there were clear things that came into being in the 14th century that have persisted long term in Western medicine. Number one is particularly the focus on anatomy. There is already anatomical interest in the period, the main period I work on, which is the 12th century. There are several texts being written that describe how to do an anatomy of a pig. And the pig, because of its long torso - and there might be other reasons as well - is considered a good enough substitute for the basic structure of human anatomy to do gross anatomical autopsies. So anatomy of the pig is being done. There are a couple of anatomical texts which seem to be feeding into a stunning rise in surgery. There's new surgical texts being written in the 12th century when there had not been any new surgical texts in the Latin tradition written since late antiquity. So after a six, seven hundred year gap, surgery suddenly comes into its own. So that's in the 12th century, but in the 14th century, as I said, with the increasing development of the practice of human anatomy - some of which is investigative, some of which is forensic in the sense of attempting to determine cause of death. Some of it is also pedagogical or even exploratory in the sense of actually trying to get a better understanding about the structure of the human body and the physiological processes that are tied to certain parts of the anatomy. 
Also in the 14th century, I would say there are some major developments in pharmaceutics in terms of new processes, new chemical processes that are being used. Distillation is more regularly being used as a way to bring out what is considered to be the essences of natural medicinal products and attempts to formalize and regularize that. So there is some way in which some of that work is being quantified as well. And the other thing that I would say is distinctive is much more regularized attention to public health, to ways in which there should be some kind of legal responsibility of urban communities to preserve health of their communities. And an important development in that respect is that it's very, very clear now that a lot of that work in terms of the legal aspects of public health starts well before the Black Death. That it's not simply a reaction to this new epidemic disease. These are basically urban concerns. It's that when you're gathering a large number of people together, it matters that you can make sure the water supply is good, make sure that the sewers are functioning well. Yes, I think there's a lot of development in this period.

Peter Adamson: What you just mentioned is clearly the thing that would leave to mind in terms of public health, but actually medicine generally for the 14th century, is the Black Death. Did they, I mean, there must have been theories that actually passed around in the medical community. I mean, obviously there were lots of ideas about what was causing the Black Death - other than just the wrath of God. What did the medical writers make of the Black Death?

Monica Green: I think crucial for understanding how we read medical texts that describe the Black Death now is that it's very clear that they are dealing with a brand new disease. This is in modern terms, we would call this an emerging disease. Something that they have never seen before. Plague had been present in Europe before, but so far as we can tell, most of the Latin medical writers don't see a connection. They don't see it as something... 'we've been through this before, there are earlier medical descriptions of this, let's dig them out and restudy them.' In the Islamic world, that's different because Islam arises during the time of the Justinianic plague. There is discussion of plague - not in the Quran, and not directly in the Hadith, but then it's discussed in other literature as well. So there is a tradition in Islamic thinking, or in texts written by Islamic scholars, where they see the continuity. Or they don't have to start from scratch in conceptualizing the disease. Whereas for Latin authors, it is completely new. So in terms of your question about what do they think causes it, there are a variety of different causal theories which are not necessarily incompatible with each other - that this is the wrath of God, but it is something that is suddenly striking many places all at the same time. Again, we've had this narrative about the arrival of the Black Death in the Mediterranean basin, in North Africa, and in Europe. We've had this for a very long time, but it's very interesting the ways in which the new genetic understanding of the history of the strains of plague that struck the Mediterranean and Europe in this period is reinforcing the narratives that we already had. This really is coming very suddenly, very quickly without any framework in which to explain it. The suddenness and the terror that it caused is palpable in ways that we're rediscovering now. And there is work starting on this path of going back and rereading those early medical treatises on plague with a new eye, with a new empathy, if you will, of what exactly they were dealing with, of how to explain such massive death, such sudden death, and death that was being caused in ways that they had never seen before.

Peter Adamson: One other thing you've worked on a lot in your research into medieval medicine is gender and medicine. Again, there's a lot we could talk about here, but I was wondering if you could just sketch for us a few of the avenues of research one could follow here. Obviously, one thing would be the treatment of women patients - who are presumably about half of patients. The other thing would be female medical practitioners, just like we have female philosophers and increasingly, in fact, have female philosophers in the 14th century, for example. Were there female physicians? You already mentioned midwives, who would be another kind of medical practitioner who is a woman. What's the general picture or does it really vary quite a bit in time and place through the medieval period?

Monica Green: What I've done in my work with respect to women and gender is actually look at three questions: how are women problematized as a category within medical understandings about physiology? To what extent is there a generic, basic human physiology that then in terms of conceptualizing physiology, conceptualizing pathology - do you see a generic human body and then specific things that have to do with a male genitalia, with a female genitalia, and so forth? Or is there the assumption that the normal human body is male and then everything about the female body is different and potentially pathological? Or is there a way in which there's some other combination of that? But asking this question of how does sex, sexual difference function in medical conceptualization? Or even how much is it gender - in the sense that something is mutable in terms of the expectations of the society? So just looking at the content of medical writing about women. Then I've looked at the question of to what extent did women contribute to those traditions? So women as authors of medical texts, women as readers of medical texts, or women as audiences of medical texts in any kind of way? And the answer to that is very, very minimal. In terms of women as authors of medical texts, the periods I've worked on, 12th century there's Hildegard of Bingen, who is also very famous in the history of philosophy for a variety of reasons. There's Trotta of Salerno, working in Salerno in the 12th century. And that's it. That's it. It won't be until the 15th century that I can find persuasive evidence that women are writing recipes, writing collections of - or gathering together collections of recipes of various kinds of practices. Now, as you already know from the work in the history of philosophy, what gets written down is not the totality of what is said, is debated, is the discourse that goes on in any community. And so then the next question is: how are women practicing medicine, even though they might not necessarily be creating a written record of what they're doing? And in that respect, I have found there's a variety of evidence. But the biggest thing that I did in my own work was ask this question about literacy. Because what literacy means, I think, for looking at women is: do you have the opportunity to engage in dialogue with people who are not present? That's really what writing does. It allows us to have dialogue - or even if it's not dialogue in the sense of it's going back and forth, that you can actually set up lines of communication across space, but across generations. That when you read Aristotle, in a way you are still engaging with a world that Aristotle perceived. Can women engage with the practices of other women? 
So one of the questions, going back to the midwife example I was talking about before: I asked the question, so again, as I said, the situation that she was dealing with was retained placenta. And really almost any medical, obstetrical text you look at, up to the present day, retained placenta is a very serious condition. If the placenta doesn't come out after birth within about half an hour is what would be considered normative. There's a huge risk of massive hemorrhaging if the placenta doesn't come out. So I asked the question, okay, we have this midwife, she's Jewish, would she have been literate, first of all? And the evidence about literacy in Jewish communities, in Jewish communities generally, is high. How much literacy there is among women is another question. Could she have read either Hebrew texts on obstetrics or Latin texts on obstetrics? Could she have participated in this longer discourse about what do you do when the placenta is retained? And what I found was that there was in fact two different lines of argument: Avicenna would have said, 'just wait, it will resolve itself, it will come out, just wait.' Another line of medical opinion was 'no, you have to reach in and take it out forcefully.' And so if she were literate, in fact that would have complicated her decision, because she had two different expectations about what the normal procedure would be. So for me it matters very much whether or not women can participate in these traditions of passing lore on from person to person, from generation to generation, and from country to country - very long distance transmission of information like that. Overall my answer was that the evidence was very, very slim. It's not simply that there were so few women as writers, but very few women who could be documented to own medical texts. And even when they did own medical texts, they weren't necessarily owning texts on women's medicine. So that's the larger picture - I think all of those questions are related.

Peter Adamson: Okay, so sort of summing up just to bring things to a conclusion: I think a lot of what you've said shows us that there are very deep parallels between the history of philosophy and history of medicine in this period. So just to mention a few of the things that you brought up, we have some participation of women, as we were just talking about, Hildegard of Bingen - in both cases actually. But just as you said, the 15th century really seems to be a kind of new period for the possibility of participation in women. I would say there's probably a bit more that the picture for women in philosophy might look a little bit better than what you were describing for the medieval period than medicine. But you still have to look pretty hard for surviving texts. There's not a lot of surviving texts by women. So that's one thing. Another thing is that you have this transformative process by which Greek and Arabic texts are brought into Latin. The choices they make as translators, everything you said about that would also apply to translations of philosophical texts, of course. And then you have the same kind of pattern of innovation and so on. And I guess my question is: is that just a kind of coincidence? Is it because medicine and philosophy travel together, that their patterns of development in this period are so similar? Or am I sort of leaping to the conclusion too quickly that medicine develops in this period sort of along the same track that philosophy does?

Monica Green: I would say there are repeated intersections between medicine and philosophy. Number one, in the sense that, as Galen would have said in the second century, 'the best physician is also a philosopher.' That so much of what physicians do is speculative. We have the word "physician" in our language now because "physic" is the task of seeing inside the body. The surgeon, for most of the period that I work on, surgery is really working on the surface of the body, taking care of broken bones and so forth. But there is no exploratory surgery. There will be almost nothing that is going deep into the cavities of the body. Pharmacy has a kind of an intellectual and in some regard even almost mathematical element, in the sense that you're trying to calculate the intensity of the medicine with the intensity of the condition in the patient's body. But with physic, it's all speculation. You're trying to interpret what is the physiology that's going on in the body. What is going on with the blood? What is going on with the urine? Urine analysis is the most symbolic aspect of medical practice in this period. In fact, many representations that you find of physicians - and I've been able to document this, and I'm sure you've seen pictures of this, of a physician holding up a urine glass. That's the iconic image, in the same way we would say somebody with a white coat and a stethoscope is the iconic image of the physician now. In the Middle Ages it would have been the urine glass, because the urine is one of the few means that you can have something coming out of the body that tells you what is going on inside of the body. But the entire process of that is speculative. And so the foundation of it is really based on Aristotelian philosophy and dialectic. And again, we don't know a lot about the earliest phases of development of medicine, but once we're talking about a university context of medicine in the 13th century and into the 14th century, these are people who would have all... to go into physics, to go into medicine, you would have already studied Aristotle. That capability of understanding that level of logical analysis is the foundation for everything that comes after it. So yes, absolutely, they go hand in hand.