by Ian Mortimer
Typhoid fever is another exception to the strangeness of the medical landscape. Whenever you have armies on the move, you have a wide variety of enteric diseases moving with them. The idea that a siege is always weighted in favor of the besieging force fails on this point: any army attacking a castle has to remain in the same place for a long time, and, as a result of poor sanitation, they tend to suffer very heavy casualties to typhoid, or “camp fever” as it is sometimes known. The same goes for dysentery. Even royalty may suffer when in the field. For all his glory at the battles of Poitiers and at Nájera, Prince Edward (the Black Prince) suffers from dysentery in the course of his long, wasting disease.35 A later warrior king, Henry V will die from it.
A third exception is poisons. Although ergotism—poisoning from rotting rye bread—is rare in England (it is not documented here before the eighteenth century) there are other natural and man-made poisons.36 The occupational hazards of working in a mine, such as lung diseases and ankylostomiasis (an infestation of parasite worms), are well known. Gongfermors are particularly at risk. Sometimes they die from the fumes in the cesspits; sometimes they die from the diseases suppurating in the pools of rotting excrement and urine. When you think that a city latrine pit may contain a thousand gallons of sewage to be cleared—at a cost of 6s 8d—you can appreciate that the danger is ever present.37 Add in the public health issue of the cleanliness of the water supply, and you can see that even having a wash after work may lead to illness. Pipes might be made of wood—elm or oak—but often they are made of lead, as in the case of Exeter’s urban water supply. The lead poisoning is not so acute that it leads to widespread nervous disorders but over the course of a lifetime of drinking lead-polluted water you can expect to see the early stage symptoms: constipation, muscular weakness, blue gums, and, discolored skin. Those workers who specialize in making lead pipes (plumbers) and laying lead roofs can expect a heavy dose of lead poisoning over the course of their career, possibly ending in nervous disorders, tremors, paralysis, and blindness.
Although they have to cope with the basic problem of crop failure, the English manage to avoid many nutrition-related diseases. Scurvy is prevented in the diets of the rich by eating plenty of cultivated and preserved fruit. It is prevented in the diets of the poor by the reliance on cabbages and root vegetables, and the storage of apples and pears through the year. Pellagra is not a problem in England, as there is no reliance on corn. Rickets—a disease in which children’s bones do not harden and are bent with muscle use, resulting in bowlegs and curved arms—is rare, for vitamin D deficiency is offset naturally as a result of sunlight acting on the skin, and children spend much of their time out of doors. So, as long as you can get enough to eat, and can avoid all the various lethal infections, the dangers of childbirth, lead poisoning, and the extreme violence, you should live a long time.
All you have to worry about are the doctors.
Medical Practitioners
As you will realize from humoral theory and the astrological basis for miasma theory noted above, medicine and religion are uneasy bedfellows. If you add the popular magic applied by ordinary people in desperate situations, you can see that it is difficult for the Church to stop people straying from religious faith and veering into the occult in search of medical relief. Besides, if the Church allows astrological means to explain a plague, why not use the same means to predict when the next plague will be? That logic leads to fortune-telling and sorcery. Thus the Church increasingly denounces medicine. As a result of the Fourth Lateran Council (1215), the Church forbids priests of the rank of subdeacon or above from engaging in any activity likely to draw blood. They are forbidden to cut into the skin, and anatomy is regarded as unholy (the Church refuses to permit Christians to dissect corpses until the late fifteenth century). The division leads to the growing separation of the professions of physic (medicine) and surgery.
PHYSICIANS
If you feel ill you will need to seek out a physician or doctor of medicine. (The term “doctor” does not become interchangeable with “physician” until the end of the seventeenth century.) This is not a straightforward matter: qualified physicians are rare. There are probably fewer than a hundred medical degree holders in the whole of England, and only the very largest cities and towns have a medical doctor in residence. Moreover, many of these highly qualified men are contracted to serve a particular household, for instance a monastery or a great lord. Their capacity for doing extra work is relatively limited. No matter how far a physician is from his lord, if the lord needs him he must attend when summoned. Because his fees are so high, he rarely refuses. When Queen Isabella is dying in 1358 she sends a horse for her physician, Master Lawrence, to come to her immediately at Hertford Castle. When her health worsens, she sends for him again, even though he is at Canterbury, seventy miles away38 As her situation is desperate, she also summons other physicians from London, twenty-one miles away. Even if you are a queen at death’s door you may have to wait a day or more for a qualified physician to come to you.
An alternative is to go to hospital. If you are admitted your clothes will be taken from you and you will be put to bed with one or two other people in a well-lit hall. Fires are lit here in winter. The floor is swept regularly and washed down every day with water. The plaster walls are redecorated every year. The linen sheets are washed regularly, perhaps even as often as twice per week. Mutton is provided three times per week, being considered a good aid to recovery. You will also be given the usual pottages and a gallon of ale each day. Medicinal baths are regularly employed. Women have their hair washed once a week; men’s beards are trimmed weekly too. All in all, the standard of care may be considered very high.39
The physician serving in a small town or a hospital is unlikely to be a university man. Most rely on brief manuals which direct the course of the diagnostic process. These include details of planets’ movements and eclipses of the sun and moon. They also include advice about phlebotomy (letting blood) and all twenty-four varieties of urine, as well as numerological methods of establishing whether you are likely to die or not. The physician will need to know when your illness started, so he can establish where the sun and moon were at the time, as well as the planet governing the health of the afflicted organ. Using these details, he will prepare a series of concoctions for you. First there is the preparative, to help your body to cope with the trauma it is about to experience. Then there is the purgative, to rid it of corrupt matter, either through vomiting, defecation, or urination. Then there is the remedy. Alternatively the physician may open a vein and let your blood. From his diagrams he will work out exactly which vein to cut in order to bleed you appropriately. This has as much to do with the moon and stars as with your symptoms. When the moon is in Leo, he should avoid incisions of the nerves and the back. When it is in Aries, he should avoid cutting veins in the head. When it is in Scorpio, he should avoid slicing into your testicles, anus, and bladder.40 If he is uncertain, or in holy orders, he will leave all this to a surgeon. After the ordeal is over, you should expect him to advise a final restorative process: good food, lots of rest, and fortifying drinks, to restore the balance of the humors.
The purgative bit is awful enough. If given orally, this might be made of linseed fried in fat or mallow leaves in ale. Alternatively, an enema containing mallows, honey, salt, and soap may be squirted up your anus with the use of a pig’s bladder. Needless to say, no one likes being bled. However, it is the remedial part of the process which will worry you most of all. The remedy for a bladder stone, as prescribed by a well-respected physician like John Gaddesden, includes dung beetles and crickets and requires you to “cut off their heads and fry them in oil.” His recipe for diseases of the spleen is not dissimilar, incorporating “the heads of seven fat bats.” Less highly qualified physicians might have even more imaginative and repulsive treatments. A treatment for jaundice reads: “Seethe wormwood in water and wash the sick man in it three times, and give him to drink ivory shaven in water.”
If you suffer from quinsy (an abscess in the throat following untreated tonsillitis), the following remedy might be prescribed:
Take a fat cat, flay it well, and draw out the guts. Take the grease of a hedgehog, the fat of a bear, resins, fenugreek, sage, honeysuckle gum and virgin wax, and crumble this and stuff the cat with it. Then roast the cat and gather the dripping, and anoint the sufferer with it.41
Not all medical recipes are animal-based concoctions. There are some which have respectably stood the test of time. You will hear physicians like Gaddesden and Nicholas Tyngewick recommend a truss for hernia and scarlet cloth for smallpox. The latter is a method which reputedly cures one of Edward II’s half brothers and may be a mark of some genuine medical intuition (infrared light is now known to prevent smallpox scars). Although no physician can cure gout, it is well known that its symptoms can be alleviated through the administration of colchicum. Likewise the medicinal properties of some herbs are widely known. Camomile oil is used effectively for earache.42 Pomegranates are correctly used for digestive ailments. The problem with such medicines is obtaining them. In 1327, when Lord Berkeley is ill at Berkeley Castle, he has to send servants to Hereford (forty-five miles away) and Winchester (eighty miles) to buy pomegranates. The journeys take several days—and the fruit, at 2s to 3s each, are certainly not cheap.43
SURGEONS
Surgeons are more commonly found than physicians. They vary in skill and experience from barbers (later called “barber-surgeons”) to highly experienced medical professionals as skilled as the best physicians. The royal household ordinances allow for there to be a royal surgeon as well as a royal physician, and these officers are known for carrying out effective operations.44 Their numbers generally are on the rise. Fewer than fifteen barbers are admitted as freemen of the city of York in the first half of the century but more than sixty are admitted in the second half45 Thus you should have no difficulty in finding a barber or surgeon to help you in any sizable town. Just look for the sign of a bandaged bloodied arm. Or, until 1307, the unsanitized version—a bowl of blood in a surgeon’s shop window.
As the name “barber” suggests (from the Latin barba, “a beard”), the principal service performed by local practitioners is that of shaving and trimming beards. However, the number of men willing to let someone come close to their throats with a sharp knife is insufficient to support many barbers. They diversify into other routine knife-related practices, such as letting blood (to maintain good health). The more surgical barbers and more specialized surgeons also undertake staunching blood flow, cauterizing wounds, opening the skull to deal with maladies of the brain, dealing with cataracts, setting broken bones, removing teeth, sewing up cut flesh, and lancing boils. Some might even consider cutting into the body to remove bladder stones—although most surgeons, if they complete this operation successfully, will kill the patient. High-status surgeons attending noblemen might also embalm their erstwhile employers, cutting open the body to remove soft parts and replacing these with herbs and spices.
The standard of surgery you might receive far outweighs that of medical advice. Obviously if a young man has an arrow sticking out of his face, no complicated lunar diagnosis is necessary. The arrow must be removed, the arrowhead drawn out, the wound dressed and sewn up, and prayers said to prevent blood poisoning. The only doubt is how best to remove the arrowhead; if it is in a leg, and not lodged in a bone, it is normally better to drive it all the way through the flesh with one strong blow than try to pull it out. For those who can afford them, good anesthetics are available. The leading surgeon John of Ardene, writing about 1370, suggests henbane, mandragora, hemlock, black and white poppies (opium), or henbane in alcohol, so the patient sleeps and that “he shall not feel whatsoever is done to him.”
John of Arderne stands out as the foremost surgeon of the century. This is partly because of his use of anesthetics, partly because of his concentration on cleanliness following the completion of his operations, and partly because of his very wide range of medical as well as surgical skills. He lives and practices in Newark, Nottinghamshire, but his books are widely copied and distributed by the end of the century. Among his most significant achievements is his rediscovery and perfection of an ancient Arabic method of curing anal fistula, a nasty affliction following abscesses in the colon which particularly affects men who have spent too long riding in wet saddles (according to Arderne). This is an advance on the medical knowledge of Gaddesden, who writes that anal fistula is incurable. Arderne also specializes in operating on other diseases of the colon and rectum. In his use of clean sponges to stem hemorrhage and his reluctance to keep changing dressings (which introduce further infections) he pioneers a new and successful approach to advanced surgery. He also has a positive attitude to treatment: not only must a surgeon have clean hands and be skillful, he must also have the ability to make his patient laugh. This is not easy when the patient in question is bent double and the surgeon is sewing up three large abscesses in the side of his rectum.
Arderne is not alone in being able to undertake advanced operations. Eye surgeons are to be found who can successfully couch cataracts, a very difficult operation. Some surgeons set themselves up as specialists in bones and do nothing but set broken limbs. Nevertheless, even Arderne has some beliefs which you will consider strange. Like all other surgeons he believes in using the “zodiac man,” a diagram linking each part of the body to a sign of the zodiac, and inferring from this when the best time to operate might be. Similarly, he believes in the virtues of bloodletting. All surgeons regard the letting of blood as prophylactic, and it is consequently one of the mainstays of their income. They perform the act usually by making an incision in the basilic vein (on the inside of the forearm, just below the elbow), and allowing the blood to run into a bowl. Alternatively, if the patient is old or weak, they might apply hot glass bowls to cut skin, drawing the blood out by means of the vacuum created by the glass as it cools. Another form of bloodletting is the application of leeches, either to suck out blood or to eat away the corrupt matter around a wound. Needless to say, all these processes are likely to do you far more harm than good. If you are unfortunate, and die from the blood loss (occasionally an inexperienced physician cuts an artery rather than a vein), it is unlikely there will be any repercussions. There is a widespread tolerance of death by medical misadventure.
10
The Law
Everywhere you go in medieval England you will see disturbing signs of the rigid and frequent application of the law. Beside crossroads you will see gallows, the bedraggled bodies of naked thieves swinging heavily on creaking ropes. On city gates you will see the putrefying heads of traitors. In town pillories you will see fraudulent traders. In the villages you will find men and women in the stocks. Every county town has its gaol, normally in the castle. On every road in the kingdom you are likely to find someone heading to a court of some sort. Justice is very visible in medieval England.
Given this, it is somewhat surprising to recall that there are no policemen. As every modern schoolchild is told, the earliest police force is the Bow Street Runners, established in London by Henry Fielding in the eighteenth century. But if this is so, who arrests all these men and women? Who detects the culprits? Who provides the links in the chain between criminal activity and the gallows?
Local Justice
In order to understand how justice is enacted in the fourteenth century we must remind ourselves how people actually live. The key aspects to bear in mind are that everyone belongs somewhere, and that people live communally. Whether they live in the town or country, whether they are free or unfree, villeins and freemen alike are known in their home town. People worship in church together. They work in the fields together. They attend the manorial courts together. Even times of celebration and relaxation are spent in one another’s company. As a result, people generally know who their neighbors are, whether they are of good character or not, and where they might have been when a crime took place.1 Those who d
o not live in such a community are vagabonds, vagrants, and strangers: on the very edge of the law, and normally presumed to be outside it.
The actual processes by which society polices itself are ancient, dating back to Saxon times. The basic element is “frankpledge.” Every male villein between the ages of twelve and sixty must be a member of a group called a “tithing.” Each member of a tithing must swear at the age of twelve to observe and uphold the law. Placing his hand on a Bible, the initiate states, “I will be a lawful man and bear loyalty to our lord the king and his heirs, and to my lord and his heirs, and I will be justiciable to my chief tithing-man, so help me God and the saints.”2 In theory, each tithing consists of ten men, but, as you will see, in reality it tends to be all those living in a hamlet or in the same street of a village. So if there are fifteen men in a hamlet, that tithing might consist of all fifteen. If one man breaks the law, all the others are responsible for reporting his actions and delivering the culprit to the constable of the township. If they do not, they are fined heavily. The leading man in the tithing, the chief tithing-man (or “capital pledge” as he is often known), is expected to make sure that his tithing is full and complete and to report the same at the manorial court and again at the hundred court. Above all else, he is responsible for ensuring that all the men in his tithing observe the law. Hence his position is one of the most important in the community.