by Lucy Inglis
Some Vikings also cultivated opium poppies, high in the north of Denmark at Viborg Søndersø (radiocarbon-dated to 1018–35), as well as its boon-companion, henbane.43 Neither are native to the area, and their presence together indicates they had been acquired from somewhere with a population that had knowledge of Graeco-Roman medicine. The Scandinavian seafarers, although they left no written records, were more than capable of travelling the world to trade.
As the Norman Conquest brought a uniform kind of Christianity to Britain in the second half of the eleventh century, back in the East, the Byzantines were facing the military might of the Turks, and in 1095 Emperor Alexios I requested help from Pope Urban II. Catholic Christianity was dominant in Europe, and Britain was drawn under Latin influence, not only in relation to the Conquest, but also the papacy’s missions to rid the north of paganism. Jerusalem had fallen to the Muslims in 637, during their rule in the Levant between 632 and 661, and the Vatican was finally feeling strong enough to make an attempt to reclaim the Holy City.
Pope Urban’s call to arms affected everyone from peasants hoping to be absolved of their sins, to aristocrats coerced into political and social alliances. The Crusades, which lasted, intermittently, until 1487, had a profound effect on European culture, literature, religious and military life, bureaucracy, and domestic life for the those left behind. Over time, the nature of these campaigns changed from pilgrimage to highly organized military campaigns led by the Roman Catholic Church. The lure of the East, across all social classes, also meant the Crusades heralded a West–East exchange on a mass scale, and brought the new wave of Eastern medicine, that of Rhazes and Avicenna, back to north and west Europe. But first, in the words of Hippocrates, ‘He who desires to practise surgery must go to war’.44
Before the Crusaders ever saw a battle, their journey presented a particular set of problems to western and northern European pilgrims. Many of them were from agrarian backgrounds, with little or no experience of living in cramped situations where maintaining supplies of clean drinking water and food was difficult, let alone fighting and sustaining injuries. Diseases of the immune system, such as leprosy, were common, as was venereal disease. Other more mundane yet agonizing ailments, such as skin problems and haemorrhoids, occurred with tedious frequency, as in any population.
At the start of the Crusades, the most skilled physicians were among the Franks, the people united in western Europe under Charlemagne, in the area that would eventually become France and Germany. These men, each known as a cyrugicus, were more like general healers who could also operate. The medical schools at Salerno, Montpellier, Bologna, Padua and Paris were already established, and provided expensive though comprehensive education for those who could afford it. Graduates were called medicus, and they were few and far between on Crusade, but the written records that remain are associated with these high-status men. Later on, in the latter part of the thirteenth century, came the physicus, with a high level of theoretical knowledge, but mainly educated in the liberal arts, and many of the physicus on campaign were clergy. The rather more grisly rasorius/barber and sanguinator/bloodletter were numerous, and probably more useful. Apothecaries only appear on Crusade in the thirteenth century, meaning drugs would have been carried by the doctor, or purchased by troops along the route.45 The evolution of this hierarchy in just over a century shows how Crusaders were rapidly understanding the variety of medical providers required by such a sustained campaign. The last such large-scale military movement across Europe had been by the Roman army, which maintained an excellent diet, high standards of personal hygiene, and a rigorous level of fitness. The Romans were also career soldiers, picked out at an early age, trained, and disciplined, bearing little resemblance to the tens of thousands of peasants and clergy, as well as the ‘adulterers, murderers, thieves, perjurers and robbers . . . even the feminine sex’ who set out from western Europe on the First Crusade in 1096–7.46
The trek across Europe towards Jerusalem, in the company of so many like-minded if occasionally shifty companions, must have been an extraordinary experience. Besides the sights and smells, the animals and sheer exoticism that abounded, there was also the reality that at some stage they would have to fight. Some of these battles were bloody, such as one in February 1098 during the Siege of Antioch: ‘Wound after wound was inflicted and the fields were red with blood. You could see torn entrails, severed heads, headless bodies, corpses everywhere.’47 These dramatic accounts were often written as religious propaganda tools, on both sides, but Crusaders did sustain serious injuries, such as blade blows amputating arms on the field, broken backs and jaw fractures.48 For the doctors and surgeons working in these conditions, Galen’s centuries-old work on dissecting pigs, dogs and monkeys came into its own. The weapons used at close quarters included swords, daggers and maces, and there were also bows and arrows, and crossbows, resulting in punctures and flesh wounds, with the attendant infections.
Extant accounts and medical texts from the early period of the Crusades indicate that European doctors used very few painkilling agents or anaesthesia, and not that often. In the face of such severe wounds, the idea of no pain relief is horrifying, and the details of disease and afflictions suffered by the European pilgrims of the First Crusade leaves the impression of a dysentery-ridden, scurvied and scarred horde.
The Jerusalem-born chronicler William of Tyre (1130–86), who became ambassador to the Byzantine Empire, was certainly familiar with opium. In his History of Deeds Done Beyond the Sea, written towards the end of his life, he mentions the dominance of Egypt in terms of opium: ‘the best opium ever discovered originated there and it is called “Theban” by physicians’.49
A contemporary of William of Tyre, the rabbi and doctor Moses Maimonides (1139–1204) was expelled from Spain as a child, and eventually settled in Fustat in Egypt. He became the personal physician to Saladin (1137–93), first sultan of Egypt and Syria, and founder of the Muslim–Kurdish Ayyubid dynasty. Maimonides wrote on the use of diryaq, an opium-based equivalent of theriac, in his Treatise on Poisons and Their Antidotes, which was used well into the Renaissance as one of the first works on toxicology. Maimonides’ works also included a Glossary of Drugs, containing a comprehensive opium commentary, and the Treatise on Asthma in which an Almoravid ruler of Morocco dies when dosed inappropriately with diryaq during an attack.50
The issue of medical negligence was addressed in a groundbreaking set of documents written shortly after Maimonides’ death, known collectively as the Assizes of Jerusalem. They were transcribed in Acre, and tell of a physician killing the servant of a client through ignorance. After a page or so of legalese, some sympathy is finally summoned for the lot of the servant’s wounds, cuts, swellings, and broken head. A short passage refers to ‘a powder or strong herb to drink’ for the treatment of ‘bowel disease’, which if the servant ‘drinks it and dies, reason judges him liable, in reason and law, to pay compensation’.51 This is unlikely to be anything other than opium.
A New Centre of Learning: Western Europe
The 200-year period of the Crusades witnessed many changes in western European society. The thirteenth century was the start of a rise in Europe’s high-status medical schools. Increasingly, medicine was a primary occupation for young men, rather than a secondary occupation for gentlemen, and occasionally women. Hersende, of Fontevrault Abbey in France, was appointed maîtresse médecin to King Louis IX on his Crusade to Egypt of 1248–50.52
Out on the Crusade route to Jerusalem, the hospitals that existed were used to cater more to the elderly and the chronically ill. The massive influx of exhausted, malnourished pilgrims, rife with sores, pests and stomach bugs, was a rude shock. Into this fray stepped the Order of the Knights of St John of Jerusalem, the Knights Hospitaller. The knights were a Roman Catholic military order, dedicated to St John the Baptist, based in Jerusalem, Rhodes and Malta. Founded around 1023, with the specific purpose of caring for the pilgrims who were flooding in increasing numbers to the Holy La
nd, the European recapture of Jerusalem in 1099 from the Muslims saw the order gain its own papal charter: charged with the care and defence of the Holy Land.
The Byzantines, meanwhile – in contrast to the monk-healer tradition of Gondeshapur to the east – had been severing the links between healthcare and religious obligation for some time, possibly as early as the sixth century, by removing monks from the wards and employing laypeople instead.53 The secular doctors worked every other month, using their time off for private practice. The Pantokrator Hospital in Constantinople employed female doctors and nurses, and had a comprehensive staff including druggists, instrument sharpeners, priests, cooks, latrine cleaners and pallbearers.54 These hospitals were working a scale unthinkable for the religious hospitals of western Europe. The collected Knights Hospitaller wards in Jerusalem could take 1,000 inpatients at a time, and 750 when it had to after a battle; their hospital even had an ambulance service, the ancestor of today’s voluntary St John’s Ambulance Service at community events in Britain.55
In contrast, the first recorded Crusader field hospital was at Acre, which in 1189–91 sustained the worst losses for the Christians in the history of the Crusades, and Germanic sailors assembled what was probably little more than a triage hut made from broken ships and sail canvas.56
No accounts of what went on inside these hospitals remain, but the things seen there – the surgeries and treatments – were taken back to the West by patients and doctors when they returned from the Crusades.
Scuola Medica Salernitana, the medical school at Salerno where both men and women attended classes, was founded perhaps as far back as the ninth century, at roughly the same time as the one in Baghdad. It had a stunning setting, inside the dispensary of a Christian monastery. In 1063, Alphanus of Monte Cassino, returning from pilgrimage to Jerusalem, arrived to teach there. Well connected and highly literate, Alphanus attracted a number of others who had also travelled widely in the East, and in Africa and India. They worked on translations of Avicenna and other influential Arabic writers, and on improving the teaching element of the school. Alphanus’ Premnon physicon is the first surviving work in Europe that mentions opium.
In 1077, Constantine Africanus, a North African Muslim convert to Christianity, arrived at the school and began teaching students. His career there is now regarded as the start of Salerno’s peak period. He translated works from the House of Wisdom in Baghdad, which were then sent to the schools at Bologna, Padua and Paris, as well as Oxford and Cambridge. One of the most famous is the Liber isogogarum, containing instructions for identifying opium overdoses. At a similar time, Trotula, later known and referred to by Chaucer as ‘Dame Trot’ in ‘The Wife of Bath’s Tale’, was working on obstetrics at Salerno. She advocated the use of opium for various female complaints, including childbirth, and after childbirth if the womb ached, and the direct application of opium to the vagina in cases of sexual frustration.57
Salerno’s combination of surroundings, religion and medical treatment meant that many sick and disabled people made pilgrimages to the school, and a series of scholars elevated the practice of medicine there. The school’s most famous teacher is Theodoric Borgognoni (1205–c.96). Theodoric’s father, Hugh of Lucca, was a well-known surgeon who had served in Egypt on the Fifth Crusade and tutored his son in medicine. Theodoric came to Salerno, and was certainly there in the 1260s, where he worked on perfecting anaesthesia using the spongia somnifera, or soporific-sponge method. In his most important work, the Cyrurgia, he includes the recipe, again including Hyoscyamus niger, or henbane, and credits his father, so it’s possible that Hugh learned of the technique while in Egypt.
take of opium and the juice of unripe mulberry, Hyoscyamus, the juice of spurge flax, the juice of leaves of mandragora, juice of ivy, juice of climbing ivy, of lettuce seed and of the seed of lapathum which has hard round berries and of the shrub hemlock, one ounce each. Mix these together in a brazen vessel then put it into a new sponge. Boil all together out under the sun until all is consumed and cooked down onto the sponge. As often as there is need, you may put the sponge into hot water for an hour and apply it to the nostrils until the subject falls asleep. Then the surgery may be performed and when it is completed, in order to wake him up, soak another sponge in vinegar and pass it frequently under his nostrils.58
Theodoric Borgognoni also believed that a wound generating pus was unhealthy, and that instead of sticky poultices and ointments, wounds and sores should be washed with wine and kept dry. He wrote on elective surgeries, such as the procedure for haemorrhoids. The repeated mention of this awkward subject in medical texts throughout the centuries seems something of a preoccupation, yet for the sufferer of this common malady, the difference between a successful operation and a botched one is incalculable. The Arab surgeons had dwelled upon it, and al-Zahrawi, known as Abulcasis (936–1013), had devised a technique perfected by Theodoric 300 years later. The account is, quite simply, agonizing, as Theodoric explains in detail the way to grapple, literally, with these painful nuisances. Yet it is also an illuminating account of what it was like to be a patient undergoing elective surgery in the late twelfth century.59 Borgognoni is the father of evidence-based medicine, a modern term for a very old concept. For the Graeco-Roman doctors such as Galen and Hippocrates, the philosophy of medicine was as important as the practice of it, but for men such as Rhazes, Avicenna and then Borgognoni, emphasis had clearly shifted to empiricism and the long-term welfare of the patient, something that began in the Islamic golden age. This rational, practical approach became widespread across Europe with the many translations of Theodoric’s Cyrurgia into vernacular languages such as Catalan.60 The Salerno school also published a small manuscript called the Regimen sanitatus salernitanum, or the Salerno Regimen of Health, which was written in simple rhymes and aphorisms, so that people could remember the recipes for medicines, and contained a variety of uses for opium. It was still in use 200 years later when printing presses meant that it could be distributed even further, with translations into Latin, Hebrew and Arabic, by which time the power balance in the exchange of knowledge shifted.
Salerno was rapidly superseded by Bologna, Padua and the new medical schools at Paris, where medicine was studied as part of an instruction in the liberal arts, and at Montpellier, where a medical school opened around 1220, and which by 1300 was one of the most important teaching centres in the world.
Merchants of Venice: The Travels of Marco Polo
By the latter part of the thirteenth century, much of western Europe had tired of the Crusades disrupting their lives and revenues, let alone that of their workforces. The emphasis had returned to trade, and the city states of Italy, such as Pisa, Genoa and Venice, were rising to dominance.
Italy’s city states, while not unique in Europe, together constituted a power unrivalled anywhere in the world. In part, this was a legacy of the order put in place by the Romans, which allowed the administration of large cities; part of it was due to an improvement in farming and climate, meaning there was sufficient food to supply these urban centres; and part of it was a rise in trade and commerce. Instead of the absolute monarchies elsewhere in Europe, these city states were merchant republics, home to mobile, adaptable and commercial people. One of the great strengths of these city states were their guilds. Focussed on the prominent trades of the time, such as goldsmithing, spices, fishmongery, salt and iron, as well as painting and drapery (cloth and silk-working), the guilds provided protection for their members, as well as for the consumer, stabilized urban markets and provided a close-knit network from which lines of credit could be extended to guilds or merchants in other cities. In the earliest guild records, opium falls under the category of a spice, and was dealt with by guilds who called themselves grocers. Venice had a particularly strong and early guild system, with a very different set of merchants than other city states, with some fifty separate guilds by the late twelfth century, reflecting the diversity and quantity of the trade there.61
So
me of these merchants were also adventurers, such as the Polos of Venice. They are certainly the most well documented, with over 150 early manuscripts of Marco’s tales of his travels and some 2,000 devoted to the family as a whole. Niccolò and Maffeo Polo were brothers and merchants from Dalmatia who came to Venice, where Niccolò’s son Marco was born, before they embarked on an epic journey east in the late 1250s. As Italy’s city states had organized themselves into individual, closeted republics, in north-east Asia Genghis Khan (1162–1227) had trampled all those who stood in his way to create the Mongol Empire, which covered most of Eurasia. Various accounts of the travels of the senior Polos cast them as diplomats and missionaries as well as merchants, but what is certain is that they were determined to make their fortunes. They lived for a time in the Venetian enclave of Constantinople, taking advantage of the quasi-diplomatic immunity of its guild system, before moving to Sudak in Crimea in 1260. Sudak at the time was part of the newly formed Mongol kingdom of the Golden Horde, and in time proved dangerous, so the brothers decamped for Bukhara, in what is now Uzbekistan. Three years later, they joined a diplomatic mission from one grandson of Genghis Khan, Hulagu, to his cousin and another grandson, Kublai, the Great Khan (1214–94) at Cambulac, now Beijing. The grandsons were dissolving the empire of Genghis into rival khanates, which made the east of Asia lucrative, if also dangerous and not a little confusing at times, but the Polo brothers spoke Turkic and possessed steady nerves.
Hulagu’s diplomatic party took the Polo brothers through Samarkand, then the Pamirs to Kashgar, and through the Gansu corridor to Changdu, the Great Khan’s summer palace, known as Xanadu to later Europeans, where they were allegedly the first Italians to meet Kublai Khan, in 1264. The khan asked them to return to Italy with a Mongol ambassador, Cogotai, as envoys to the pope, to ask for oil from the lamp of Jerusalem’s Holy Sepulchre, and a hundred men ‘acquainted with the Seven Arts’ – grammar, logic, rhetoric, arithmetic, geometry, music, astronomy – who could teach his people about Europe. Like many of the Mongol rulers he was largely indifferent to religion, but recognized its importance in bringing as many people and as much territory under his control as possible. This is reflected in his choice of Uyghur, the tongue of his most wide-ranging ethnic group, as the written language of his empire. The brothers were given some asbestos cloth as a gift for the pope, which could only be cleansed by fire, and a gerege, a tablet of gold one foot long by three inches wide, bearing the inscription ‘By the strength of the eternal Heaven, holy be the Khan’s name. Let him that pays him not reverence be killed.’ In what became trademark Polo family style, they managed to shed the burden of ambassador Cogotai in some nameless town when he apparently became too ill to travel, and continued back to Venice as the khan’s envoys to the pope. They arrived in 1269, having shown the gerege to ensure their safe, and fully expensed journey, and pausing to transact business along the way. What happened to the valuable asbestos cloth is unknown. In Venice they collected Niccolò’s teenage son Marco, and then set out for China once more, this time as envoys of Pope Gregory X to the Great Kublai Khan.